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MAR 2? 1885 



A GUIDE 



TO THE 



DISEASES OF CHILDREN. 



PRACTICAL TEXT-BOOKS AND MANUALS, 
FOR PHYSICIANS AND STUDENTS. 

Yeo's Physiology. 300 Illustrations and Glossary. Cloth, $4.00; Leather, $5.00 

Roberts' Practice oi Medicine. Illustrated. 5th Ed. Cloth, $5.00; Leather, $6.00 
Reese, Medical Jurisprudence. Cloth, $1.00; Leather, $5.00 

Biddle's Materia Medica. 9th Edition. Cloth, $4.00; Leather, $1.75 

H old en ' s Anat. and Manual of Dissections. 200 Illust. 5th Ed. CI. $5.00 ; Lea. $6.00 
Rindfleisch, Elements of Pathology. Ed. by Prof. Tyson. Cloth, $2.00 

Bruen's Physical Diagnosis. Illustrated. 2d Edition. Cloth, §1.50 

Byford's Diseases of Women. Illustrated. 3d Ed. Cloth, $3.00 ; Leather, $6.00 
Gilliam's Essentials of Pathology. Illustrated. Cloth, $2.00 

Heath's Minor Surgery and Bandaging. 115 Illustrations. 6th Ed. Cloth, $2.00 
Kirke's Physiology. Illustrated. 11th Edition. Cloth, $5.00 

Marshall and Smith, Chemical Analysis of Urine. Cloth, $L.OO 

Meigs and Pepper, Diseases of Children. 7th Ed. Cloth, §6.00; Leather, $7.00 
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Richter's Inorganic Chemistry. 3d Edition. 90 Illustrations. Cloth, $2.00 

Richter's Organic Chemistry. 4th Edition. Illustrated. In Press. 

Roberts' Compend of Materia Medica and Pharmacy. Cloth, $2.00 

Tanner's Index of Diseases and Their Treatment. Cloth, $3.00 

Tyson's Examination of the Urine. Illustrated. 4th Edition. Cloth, $1.50 

Van Harlingen, Skin Diseases and Their Treatment. Illustrated. Cloth, $1.75 

P. BLAKISTON, SON & CO., 

No. 1012 WALNUT STREET, PHILADELPHIA. 






A GUIDE 



Diseases of Children. 



JAMES FREDERICK GOODHART. M.D..F.R.C.R. 

ASSISTANT PHYSICIAN TO GUY'S HOSPITAL, AND LECTURER ON PATHOLOGY IN ITS MEL ICAL 
SCHOOL; PHYSICIAN TO THE EVELINA HOSPITAL FOR SI3X CHILDREN. 



REVISED AND EDITED 



LOUIS STARR, M.D., 

CLINICAL PROFESSOR OF DISEASES OF CHILDREN IN THE HOSPITAL IF THE UNIVERSITY OF 
PENNSYLVANIA; PHYSICIAN TO THE CHILDREN'S HOSPITAL, PHILADELPHIA. 



WITH FORMULAE. 
PHILADELPHIA: 



P. BLAKISTOX, SOX & CO. 

1012 Walnut Street, 
i 88 v 



\S 



Copyrighted, 1885, by P. Blakistox, Son & Co. 



PREFACE 
TO THE AMERICAN EDITION. 



In preparing this edition of Dr. Goodhart's work on Dis- 
eases of Children, the editor, without altering the author's 
graphic text, has made such additions as, in his judgment, 
seemed to make it more valuable to the American 
reader. This new matter has been either inclosed in 
brackets ( [ ] ) or inserted as foot-notes. 

It is the author's evident intention that his book shall 
cover the, hitherto unoccupied, ground between the too brief 
handbook on the one hand and the exhaustive treatise on 
the other. This object the editor trusts he has been able 
to further, through his" experience of the wants of junior 
practitioners and students. 

His thanks are due to Henry D. Harvey, M.D., for 
efficient aid, both in the preparation of the text and index. 

Louis Starr. 

1922 Spruce Street, Philadelphia, 
April, 1885. 



AUTHOR'S PREFACE. 



Many medical students have expressed to me their want 
of a Manual upon Diseases of Children. To this, and to 
a request from the publishers that I would fill up a gap that 
appeared to exist in books on this subject, the appearance 
of the present volume is due. 

As regards the scope of the work — in writing a book 
upon the diseases of children I have not considered it my 
function to write one on general medicine, but so far as 
possible I have kept in view the diseases which seemed 
to be incidental to childhood, or such points in disease as 
appear to be so peculiar to, or pronounced in, children as 
to justify insistence upon them ; and if the book meets 
the want it aims to supply, it will be due, I think, as much 
to its omissions as to its contents. For example, in 
dealing with pneumonia and bronchitis, there will be found 
no minute description of physical signs ; in heart disease, 
no consecutive account of such general symptoms as are 
common to all ages of life. I have taken for granted that 
the student already possesses some knowledge of general 
medicine, and have dwelt upon such points as belong 
peculiarly to childhood. This will explain a certain 
amount of disconnectedness which runs through the 



5 PREFACE. 

volume; and if beyond this it still be thought that I have 
been less precise than is desirable, I would reply that it 
is always difficult to be at the same time dogmatic and 
exact. " Knowledge brings doubt and exceptions and 
limitations, which are all hinderances to vigorous state- 
ment." Moreover, what may be considered a fault in some 
ways, is not without some and perhaps equivalent advan- 
tages ; not the least being the fact that this conception 
of the student's wants has enabled me to follow more 
closely my own bent than would have been possible in a 
more systematic treatise. I am not without hope that in 
thus acting I may have accomplished at least one aim — 
viz., to supplement, not to supersede, the admirable text- 
books already existing on the diseases of children. My 
obligations to these already published works I cannot 
attempt to sum, unconscious memory playing so large a part 
in the thought of every one of us. But this much I can say, 
that it gives me no common pleasure to confess how much 
I owe to West, Rilliet and Barthez, Hillier, Eustace Smith, 
Henoch, Gerhardt, Steiner, Meigs and Pepper — amongst 
others — and last but not least to two of the most realistic 
writers of our own day, Dr. Samuel Gee and Dr. Thomas 
Barlow. I have also availed myself of the observations 
upon the incubation of some of the exanthemata, which have 
from time to time appeared in the Lancet during the last 
few years from the pen of Dr. Clement Dukes, of Rugby. 
Dr. Dukes's work in this direction is some of the most 
valuable that exists. 

Of others who have more immediately helped me I 



^ 



PREFACE. 9 

must thank Dr. Newnham, our present resident medical 
officer at the Evelina Hospital, for aid on several occasions. 
Mr. Collier, head of the dispensing department at Guy's 
Hospital, has been kind enough to revise the Appendix 
of Formulae, and my brother, the Rev. C. Alfred Goodhart, 
of Sheffield, and Dr. Lewis Marshall, Surgeon to the 
Hospital for sick children at Nottingham, have been at 
much trouble in revising and criticising the proof-sheets. 
Of the labor thus ungrudgingly bestowed I alone can fully 
appreciate the value. 

James F. Goodhart. 



CONTENTS. 



CHAP. PAGE 

Introduction, ,. .13 

I. Dentition, 28 

II. Diet of Children in Health, ..... 32 

III. Diet Diseases: Atrophy — Flatulence— Colic— Con- 

stipation, 46 

IV. Diarrhcea — Entero- Colitis — Cholera Infantum, . 60 
V. Stomatitis — Thrush— Cancrum Oris, .... 88 

VI. Diseases of the Digestive Tract, . . . .105 

VII. Diseases of the Digestive Tract [continued), . .114 
VIII. Worms, . . . . . . . . .135 

IX. Intussusception, . . . . . . . . 143 

X. Measles, 157 

XI. Scarlatina, . . .172 

XII. Rotheln — Roseola, 203 

XIII. Diphtheria, 210 

XIV. Varicella — Vaccina — Vaccination, . . . . 240 

XV. Mumps, 249 

XVI. Whooping-Cough, 255 

XVII. Typhoid Fever, 279 

XVIII. Malarial Fever, 291 

XIX. Diseases of the Respiratory System, .... 294 
XX. Laryngeal Spasm — Laryngitis — Warty-Growths — 

Foreign Bodies in the Trachea, Etc., . . . 303 

XXI. Bronchitis and Bronchiectasis, 327 

XXII. Pneumonia, ^^7 

XXIII. Atelectasis — Phthisis, 354 

XXIV. Pleurisy, 373 

XXV. Acute Tuberculosis, 393 

XXVI. Scrofula — Leukaemia — Bronchial Phthisis, . . 398 

XXVII. Tabes Mesenterica and Tubercular Peritonitis, . 410 

XXVIII. Peritonitis and Ascites, 418 



1 2 CONTENTS. 

CHAP. PAGE 

XXIX. Diseases of the Spleen, 429 

XXX. Diseases of the Liver, 433 

XXXI. Diseases of the Genito-Urinary Organs, . . .441 

XXXII. Diseases of the Nervous System, .... 455 

XXXIII. Tubercular Meningitis, 464 

XXXIV. Hydrocephalus, 474 

XXXV. Intra-Cranial Tumors, 485 

XXXVI. Hypertrophy of the Brain — Cerebral Hemor- 
rhage — Thrombosis of the Cerebral Sinuses, . 490 

XXXVII. Disorders of Movement, 496 

XXXVIII. Motor Disorders {continued), 517 

XXXIX.' Infantile Convulsions — Epilepsy — Night Terrors, . 536 

XL. Functional Nervous Disorders — Headache, . . 545 

XLI. Idiocy and Cretinism, 550 

XLII. Chorea, 557 

XLIII. Rheumatism, 578 

XLIV. Heart Disease— Paracentesis of the Pericardium, . 595 

XLV. Purpura — Haemophilia — Scurvy— An.emia, Etc., . 623 

XLVI. Rickets and Bone Softening, 633 

XLVII. Infantile Syphilis, . 663 

XLVIII. Diseases of the Skin, 677 

Appendix of Formula, 703 

Index, 717 



1 



THE 



DISEASES OF CHILDREN. 



INTRODUCTION. 

What is a child, and how the diseases of children differ 
from the diseases of adult life, are questions which must 
have confronted all who have written upon the ailments of 
childhood, and not a little puzzled them for an answer. By 
the pathologists, indeed, it may well be doubted if any valid 
reason can be given for separating diseases of children from 
others, for there are but few morbid changes found in child- 
hood that are not to be seen at one time or another in the 
bodies of adults. 

If we run over the various regions of the body, the brain, 
heart, lungs, lymphatic glands and so on, few, and those 
but minor, differences can be pointed out between the pro- 
ducts of disease in the child and of the same disease in an 
adult. Some diseases are more common at one time of life 
than at the other ; but should they overstep the limit of age 
usual to them, they appear in their old form, or with but 
slight modifications, such as would certainly not justify any 
one in devoting a "manual " to their description. 

The bones form the most notable exception to this rule: 
in rickets, acute ostitis, and some forms of enchondroma we 
have examples of constancy of peculiarity of morbid deposit ; 



14 THE DISEASES OF CHILDREN. 

of constancy of limitation to the growing age; of constancy 
of peculiarity of distribution of the disease, and so on. Cer- 
tain diseases of the skin artd teeth might equally be advanced, 
but having said even this, we should still be at fault for ma- 
terial for a book. The difficulties and differences which 
render it advisable that these diseases should receive special 
study are mostly those of semeiology and treatment, and 
from the fact that the student when first introduced to this 
branch of practice finds himself thrown upon his own re- 
sources. ' In the adult he can ask questions and obtain clues 
to the furtherance of his diagnosis. With infants and chil- 
dren he must find out what he can for himself — the history 
is faulty or often quite wanting — and here he fails. For 
instance, it is a common occurrence in hospital practice to 
find that no account is forthcoming from the clinical clerk 
of some child that has been admitted since the last visit. 
He has not yet seen the mother, is the explanation of the 
remissness which is offered. Supposing now that we change 
the venue, so to speak, of this illustration to that of the 
veterinary surgeon, and one of the lower animals, and such 
an answer, were it conceivably possible, would be ludicrous. 
Yet, there is not so very much difference between the student 
who has to investigate the diseases of children and one who 
has to do with diseases of the lower animals. In both cases 
the diagnosis will chiefly rest upon the doctor's mere ob- 
servation and examination. In both intelligible speech is 
wanting. I am by no means desirous of underrating the 
history which a parent or relative can give ; on the contrary, 
an intelligent mother and nurse are to be listened to patiently 
and attentively — they are often acute observers of early 
signs of ill health, or changes in the symptoms. All I wish 
to enforce is, that the previous history occupies a subordi- 
nate, not the chief, position, and the student is at all times 
to consider himself as independent of it. Any help that can 



INTRODUCTION. 1 5 

be obtained in this way is all well and good, but it is to come 
after, not before, a personal examination. 

Supposing now that a child iff before us, what is to be 
done in making a thorough examination ? Our first care 
will be not to frighten the child, a task which at once calls 
into play tact, patience, and control of feeling. A strange 
face is alone sufficient to make a child cry, but when that 
face belongs to the doctor, a word very early added to the 
child's small repertory, and when these are associated in- 
delibly with memories of castor oil or Gregory's powder, 
inexperienced nature can hardly be expected not to revolt — 
and revolt it often does, regardless sometimes of the most 
exquisite tact. But much can be done to soothe matters by 
the expenditure of a little trouble; never be in a hurry; take 
time, that the child may become accustomed to you ; talk to 
it, play with it, show it any glittering thing that may be at 
hand, and give it the stethoscope to play with. Any instru- 
ment that it may be necessary to use should first be made a 
plaything, the subsequent examination being often much 
facilitated by so doing. Do not touch a child till it has had 
a good look at you. Plenty of occupation is afforded in the 
meantime by talking to the mother or nurse. Then, with 
regard to special instruments, the thermometer, for instance, 
which is constantly in use, put it into the axilla and hold it 
there gently, with your eye on the column of mercury, 
talking to the child all the while, and even drawing its at- 
tention to it. If the forearm is not restrained it will be 
possible to do this for a minute or two, during which you 
may watch the mercury quickly rise to a certain height, and 
then proceed more leisurely. If the child become restless, 
withdraw it; the half degree or so which it may rise after- 
wards will be of little importance to you in drawing conclu- 
sions, whereas a fit of. crying or any fright will render all 
further observations difficult. [In infants, however, it is best 



1 6 THE DISEASES OF CHILDREN. 

to take the temperature in the rectum, since the surface heat 
varies greatly with that of the surrounding atmosphere, and 
since it is difficult to maintain quiet long enough for an 
axillary observation. The well-oiled bulb of a thermometer 
should be gently inserted through the anus, and kept in place 
for three minutes. The normal temperature in this position 
is about 99 F.] 

With the ophthalmoscope again try to get it to consider 
the instrument as a toy, the examination a game of play, 
and — with plenty of patience, for a child's eye partakes of 
the restlessness of its whole muscular system, and no 
fixed look at any object, however attractive, can be counted 
upon for more than a second or two — there are few children 
or infants in whom the optic disks may not be seen. It 
is essential to success in many cases not to touch the 
child. As soon as a finger is placed on the forehead to steady 
the lens used for the indirect method, many a child will 
rebel. The same remark applies still more forcibly to pulling 
up the upper lid to obtain a view of the pupil. The attention 
must be attracted by playing the light on and off the eye; 
and skill will come with practice in ascertaining the state of 
the fundus by repeated momentary glimpses rather than by 
any one prolonged view. Even the haemacytometer, for 
which it is necessary to prick the finger, may be used with- 
out making a child cry, by making a rapid prick with a 
needle and showing the resulting drop of blood to the child 
as a wonderful thing. Let me next say that the child is to 
be restrained as little as possible in any examination that 
may be necessary. The mother or nurse will often hold its 
hands or its legs, or both, as the firs? step to auscultation, 
and there is nothing which a child resists more than restraint 
of this kind. Let it kick about, if it will, till it becomes 
unmanageable, and this will but seldom be the case if we 
take care not to make it so. Let it play with the end of the 



INTRODUCTION. 



17 



stethoscope, if it likes; it is quite possible to distinguish the 
respiratory sounds, and after a time those of extraneous 
origin can be as readily ignored as can the noise made by 
a crying child. The fact that the child is crying is no excuse 
for not examining the chest — crying necessitates deep res- 
piration, and is often advantageous for this reason. All that 
we need is more patience. In auscultation, also, it is often 
necessary to listen to the respiratory or heart sounds in 
snatches, and to fill in by repeated observations what is not 
permitted by continuous examination ; and in many cases it 
is advisable to examine the back of the chest first. 

Having given these few hints upon what to avoid, a few 
may follow concerning what has to be done — and first we 
must be careful to maintain an attitude of close observation. 
The points to be observed are often apparently trivial and 
difficult to keep in mind in any systematic way. There is 
the complexion of the child ; the formation of its bones ; 
the state of its skin and muscle — is it fat, spare, firm, or 
flabby; its size in proportion to its age; its general build; 
the shape of its head ; the state of its fontanelle ; the relative 
proportions of head and face ; the condition of corneae and 
pupils ; the lines upon the face ; the state of the nostrils ; 
the gums, the teeth, the tongue; the ears; the shape of the 
chest and its movement ; the abdomen and its movement ; 
the character of the cry and the state of the nervous system. 
All these facts and many more, indicating as they do points 
negative and positive which are absolutely essential to the 
formation of a diagnosis, and for forecasting the issues of the 
case, and for treatment, must yet, being but preliminaries, 
often be taken in hurriedly, almost at a glance. To allow 
of this being done in any sense completely, it is well to take 
each step in a regular method. Start where you like, adopt 
your own plan, but proceed as much as possible upon this 
plan : and while rapidity of execution comes with practice, 



1 8 THE DISEASES OF CHILDREN. 

abundant compensation will be obtained for any trouble that 
may be involved, in the frequency with which, by so doing, 
conclusions will be arrived at, and results obtained, which 
had not previously been expected, and would in all proba- 
bility have been missed by less methodical observation. 

It is impossible, in a short manual, to go much into detail 
in a preliminary chapter, but one or two points may be 
selected to illustrate the importance of what has been said. 
For instance, the cry of a child may help to distinguish the 
ailment under which it is laboring, There is the noisy, 
passionate cry of hunger; the wail of abdominal disease; 
the whine of exhaustion ; the short, sharp shriek of cerebral 
disease ; the hoarse, whispering cry of laryngitis. 

Much may be learned by a glance at the shape of the head. 
The hydrocephalic head is one which bulges in all direc- 
tions. The forehead projects, the temporal fossae become 
convex ; the fontanelle and vertex more vaulted ; even the 
occiput becomes more rounded, and, in this general tendency 
towards the assumption of a globular form in place of an 
ovoid, the inter-ocular space is widened outwards, and the 
eyes are rendered too divergent. The rickety head is an 
elongated one, and often laterally compressed, and although 
the forehead may be overhanging, it wants the width and 
general rounding seen in hydrocephalus. [More frequently 
the rachitic head is square, being flattened anteriorly, poste- 
riorly, superiorly, and laterally. The frontal eminences are 
prominent, and the sutures are depressed, and with the 
fontanelle late in closing. There is also apparent enlarge- 
ment, due to comparative smallness of the face from arrested 
development of the facial bones ; actually the cranium 
measures about the same as for the corresponding age in 
health.] The head of the syphilitic child is sometimes of 
irregular shape, almost lobulated in appearance, and betrays 
its component bones by the position of the enlargements. 



INTRODUCTION. 



19 



The disease is one of osteophyte growth, which forms upon 
the bones round the anterior fontanelle, and spreads thence 
over their surfaces. The fontanelle may thus appear to lie 
in a hollow, the frontal bone # being unusually prominent, 
and the inter-frontal suture converted into a vertical ridge, 
from the exuberant bone formation along it; while the 
parietal bones become bossed irregularly. This skull has 
been called the natiform skull, from the appearances pro- 
duced by the bony elevations. It is still an open question 
whether the osteophytic growth is due to syphilis or to 
rickets. The scaphoid skull is a narrow skull, in which the 
frontal region is boat-like, and slopes away from the median 
line, betokening the small brain of an imbecile or idiot. 

The fontanelle, by bulging, may indicate excess of blood 
or cerebro-spinal fluid within the cranium ; by its size it 
may indicate defective ossification, and so rickets ; but of 
more importance, because of almost invariable significance, 
is the depressed fontanelle of starvation and exhaustion : it 
indicates the immediate necessity of food or stimulants. 

Then we might take the face, and mention that shades of 
pallor are most suggestive — a dirty white stands for con- 
genital syphilis ; a sallow white for splenic disease ; a pallor 
with a sub-tint of blue for tuberculosis ; a livid, leaden, or 
earthy tint for collapse from abdominal disease. 

There are certain markings upon the face, Jadelot's lines, 
as they are called, from the French physician, who has de- 
scribed them very fully. [These lines are: 1st. oado-zygo- 
matic, indicating disease of the brain. This begins at the 
inner angle of the eye, and extends outward beneath the 
lower lid, to disappear a little below the projection of the 
malar bone; 2d. The nasal, pointing to gastro-intestinal 
disorders, or affections of the abdominal viscera. This rises 
at the upper part of the ala of the nose, and passes down- 
ward, to form a semicircle around the corner of the mouth ; 



20 THE DISEASES OF CHILDREN. 

3d. The labial, denoting disease of the lungs and air-passages. 
Beginning at the angle of the mouth, this line runs outward 
and downward, to be lost at the lower part of the face.] 
Then there are the various complexions which are supposed 
by many to indicate particular diatheses or tendencies to 
disease — the pretty, thin-skinned children of tubercular pro- 
clivities; the sallow, muddy appearance of children prone 
to glandular abscesses ; the dark-haired, pallid, but, on 
the whole, well-liking children of nervous habit, and so 
on. Of these, though they have in former times occu- 
pied much of the attention of writers of books, I shall say 
but little, because there is now considerable want of una- 
nimity upon the subject, and because their importance is 
hardly measurable by facts, but depends upon observations, 
the accuracy and worth of which the student must test for 
himself. There is the sunken eye, the dark-colored and 
depressed areola around it, indicative of collapse ; the dilat- 
ing alae nasi of acute lung disease; the lividity of lips of 
chronic lung disease ; the puffy, congested eyelids, and 
ecchymosed face of whooping-cough. 

For the chest, we have the immobility of pleurisy; the 
unnatural praecordial bulging of a large heart; the sinking 
in of the lower ribs of atelectasis. Of the abdomen, it may 
be said that enlargement is not necessarily due to disease. 
Children will constantly be brought to you for " consumption 
of the bowels," because they have diarrhoea and a large 
stomach. In the great majority of cases, the enlargement is 
due to flatulent distension from defective feeding, sometimes 
to displacement of the liver and spleen by distortion of the 
thorax in rickety children. In many such there will be but 
few cases of organic disease, and of mesenteric disease, it 
may be said that it is but seldom associated with any abdo- 
minal enlargement sufficient to attract the attention of the 
child's mother, and in my experience there has not often 



INTRODUCTION. 



21 



been any disease of the glands that could be felt by palpa- 
tion. Increase in size of the abdomen, when the result of 
disease, may be due to a large liver or spleen, sometimes to 
ascites, sometimes to tumors connected with the kidney. 

When we come to the more personal examination of the 
child, I would still inculcate the necessity of routine. It 
matters not how we proceed, so long as some definite plan 
is reguarly followed. Supposing, as is probable, that some 
idea of the nature of the case has been gleaned from the pre- 
liminary survey, it is a good plan to start with the organ 
which we suspect to be involved. If there be any reason 
for suspecting disease of the nervous system, it is as well at 
once to examine the eyes with the ophthalmoscope, lest any 
subsequent action on our part may frighten the child, and 
render the fundus oculi inaccessible. It is impossible to 
make any satisfactory use of the ophthalmoscope if the child 
is, or has been recently, crying. This done, and the state 
of the pupil and movement of the eyeball ascertained, the 
sight and hearing can be tested by a watch ; and the pre- 
cision of the various muscular movements of the extremities, 
by giving the child something to hold or pick up, and by 
making it walk, if old enough, or by watching the move- 
ments of the limbs in infants too young to walk, as they lie 
on the mother's lap. The gums can be examined, and the 
progress of dentition ascertained by gently rubbing the sur- 
face of the gums with the finger. The chest and abdomen 
should be examined in all cases. Some advise that the child 
should be stripped for this purpose, and this is a necessary 
measure in some cases. I do not advise it as a rule, for the 
reason which I have adopted throughout these suggestions, 
viz., that the child is to be frightened or put out of temper 
as little as possible. Children, all but the youngest infants, 
resent the process of undressing, and it is usually sufficient 
for our purpose, that all the clothing be loosened. The 



22 THE DISEASES OF CHILDREN. 

greater part of the front and back of the chest can be, by 
this means, exposed, and a thorough examination made. 
Percussion must be light or it will mislead. A light vertical 
tap with one or two fingers upon a finger of the other hand 
placed flat upon the chest is all that is necessary, and special 
attention is to be paid to the intervertebral grooves, as parts 
which are more frequently implicated in children than in 
adults. In auscultation it is very essential to make careful 
comparison of the two sides ; of the bases with the apices; 
and to remember that it sometimes happens that the more 
abnormal sounds are heard in the healthier lung. A student 
will often describe as bronchial breathing, the exaggerated, 
puerile respiration of the over-acting, but sound lung, and 
consider as healthy, the soft and deficient vesicular murmur of 
the diseased side, and indeed there is abundant excuse for his 
so doing. Again, disease maybe ascribed to the apex of the 
lung from the existence of bronchial breathing, whereas the 
primary disease is really at the base. Therefore, the whole 
of the chest must be auscultated : above and below the clav- 
icles ; the supra-spinous fossae behind ; the intervertebral 
grooves and bases ; and we must be on the alert to detect 
even slight differences between the two sides. 

The examination of the abdomen is chiefly conducted by 
means of palpation — enlargement of the spleen and liver 
are ascertained in this way. So, also, other abdominal tu- 
mors. But there are other points of detail which are well 
worth attention. In the first place it is often worse than 
useless to put a young child on its back and uncover it for 
examination. It will kick and scream, put its muscles into 
a state of rigidity, and nothing can be made out. One must 
often be content with an examination while it is sitting up 
and by placing the hand beneath its clothes. It is equally 
useless to poke the abdominal wall with the tips of two or 
three fingers, as the muscles are provoked to action by this 



INTRODUCTION. 23 

means also, and nothing can be felt behind them. Palpa- 
tion can only be properly conducted by placing the warm 
palm perfectly flat and open upon the abdominal wall and 
making pressure at any part that requires examination with 
the flat of one or two fingers. Any abnormal tumors can 
in this way be readily detected, and their edges defined — 
be they hepatic or splenic or what not. Splenic and renal 
tumors are best examined by one hand being placed flat 
beneath the body supporting the hinder wall of the abdo- 
men, while the other, flat and open as before, makes pres- 
sure from above upon the abdominal wall supported by the 
hand behind. 

[The pulse, in infancy, ranges from 90 to 130 beats per 
minute; the least muscular effort or emotion of anger or 
fright being sufficient to increase the frequency of the heart's 
action from the former to the latter figure. As a test of 
physical strength, the pulse, at this age, is far less reliable 
than the condition of the fontanelle. After the age of two 
years, it becomes a more valuable guide. In health it rarely 
counts more than ico during the waking state, and is some 
10 or 20 beats slower in sleep, when, too, it is often irregular 
in rhythm. An increase to 130 occurs with any trifling 
fever, and is consequently not a serious symptom. Abnor- 
mal slowing, on the contrary, is a grave feature, a reduction 
to 40, for example, frequently attending tubercular menin- 
gitis. 

The respiration varies in frequency with the age. At 
birth, the average is 40 per minute; from two months to 
two years, 35; and from two to twelve years, 18 during 
sleep, 23 while awake. The movements should be dia- 
phragmatic; if superior-costal, a painful abdominal disease, 
as peritonitis, is indicated ; if abdominal, pleuritis or pneu- 
monia. Very rapid breathing attends cardiac disease and 
inflammatory affections of the lungs or pleura ; slow, sigh- 



24 THE DISEASES OF CHILDREN. 

ing respiration, interrupted by long pauses, tubercular men- 
ingitis. The normal ratio of respiration and pulse is I to 
3 or 3.5. Should this be changed to 1 to 2, pneumonia or 
pulmonary collapse may be suspected.] 

The ejecta of children should all be examined, whether 
they be vomited or passed from the bladder or rectum. 

The sleep of a child should be watched if opportunity 
offer. A child sleeps quite calmly when in health, and for 
a long time at a stretch when the first few months are passed 
over and the necessity of frequent suckling has gone by, 
but it is quickly disturbed in ill-health of all kinds. Slight 
attacks of fever, gastro-intestinal derangements, dentition, 
brain disease, etc., all make the sleep uneasy, although not 
much differentiation of disease can be accomplished by ob- 
servations of this kind. The manner of deglutition is an- 
other feature which often conveys an indication of disease. 
For in any interference with the freedom of respiration a 
child will take a few snatches of food and then turn away 
and splutter, or cough, or cry. If children refuse food with- 
out any definite reason, the mouth and throat should always 
receive a careful examination ; stomatitis, tonsillitis, and even 
more serious troubles, such as post-pharyngeal abscess may 
otherwise go unrecognized. 

By persistently following out the spirit of these prelim- 
inary suggestions in the way that seems best suited to the 
individual examined, it will be but seldom that a very refrac- 
tory child is met with, or that you fail to make a satisfactory 
examination. 

Treatment. — I had purposed to devote a chapter to spe- 
cial points in the treatment of children, but thinking the 
matter over, the necessity, nay even the wisdom, of so doing 
may be doubted. For, after all, the dosage for children, the 
one great dread of students, is a matter which, if stated with 
precision in a posplogical table, is never handy for reference, 



INTRODUCTION. 25 

and is hardly reliable if it be. [Nevertheless, as a guide to 
the student, Cowling's rule is serviceable ; namely, the pro- 
portionate dose for any age under adult life is represented 
by the number of the following birthday, divided by twenty- 
four, i.e., for one year A = A; for two years A = i, and so 
on]. With one or two exceptions, every one must make his 
own table in his own memory, and must feel his way. 
Herein is one of the advantages of experience, which can 
hardly be gained in any other manner. Opium has been a 
great bugbear in this respect. All powerful drugs must 
naturally be given with caution to children ; but opium is 
perhaps the only one which requires excessive precaution. 
It must be given to infants in infinitesimal proportions, and 
there are some practitioners who evade its use at this time 
of life as much as possible. Still, combined with castor-oil, 
it is a useful drug in bad cases of flatulent colic, and perhaps 
one drop to a two-ounce mixture, of which a drachm may 
be taken, is an average dose in the first six weeks of life. 
This quantity may have to be lessened, but it will certainly, 
in many cases, be necessary to increase it, and after the first 
two or three months the extreme susceptibility to the drug 
disappears, and half a drop may then be given for a dose. 
At two or three years old, two-grain doses of Dover's powder 
may be given, when requisite, without fear. 

Bromide of potassium, a most valuable remedy in many 
of the diseases of children, must be given to infants with 
watchfulness. It sometimes, even in small doses, produces 
severe local inflammation of the skin, and localized patches 
of soft, warty growths. This is, however, of infrequent 
occurrence, and cannot be avoided when, as is sometimes 
the case, the idiosyncrasy is so pronounced that three or 
four grains suffice to produce the eruption ; but, for the 
reason that there is a risk, the drug should not be continued 
for any length of time, except under close supervision. 



26 THE DISEASES OF CHILDREN. 

Belladonna and arsenic are illustrations of an opposite 
tendency, for children are very tolerant of these drugs, par- 
ticularly of belladonna. A child four or five years old will 
take fifteen to twenty drops of tincture of belladonna without 
any inconvenience whatever.* And in such cases as it is 
necessary to give arsenic,*usually in children six years and 
upwards, a dose of seven drops of the liquor arsenicalisf may 
be given at the onset three times a day, and a considerable 
increase on this be attained if necessary. But children do 
not often require a very energetic treatment with drugs, and 
probably he will be the best practitioner who lets Nature 
make for cure without heroic measures. Proper feeding 
ranks first in all treatment in early life. 

It is not unnecessary to add that all drugs should be made 
as palatable as possible. Castor oil and Gregory may be 
very good remedies, but, except to babies, they are very 
disgusting, and there are now at hand numberless substitutes, 
and methods of disguising nasty remedies, which should be 
studied. Some maybe put into lozenges, some into syrups, 
some mixed up into a palatable emulsion, and so on. 

I must, however, allude to baths for children, because their 
sphere of usefulness is large. It would probably be difficult 
to enumerate the variety of diseases in which a bath is use- 
ful. As a general rule when a state of pyrexia is recognized, 
the child is likely to be smothered to keep it warm. For 
the same reason, the linen which is not actually soiled by 
the excreta, is not changed for fear of chill. But children 
of all ages* perspire freely, and in the course of a few hours 
will get exceedingly uncomfortable under these circum- 
stances, fretting and becoming restless, whilst the mother 
wonders why sleep does not come. Put the child into a 

* It must be remembered that Tincture of Belladonna Br. P., is only 
about half as strong as the same preparation U. S. P. — Ed. 
f Equivalent to liquor potassii arsenitis, U. S. P. — Ed. 



INTRODUCTION. 



27 



warm bath for a few minutes, and with fresh linen and a 
comfortable cot it will probably soon be at rest. Then, too, 
in most states of fever, sponging is of value — warm, or tepid, 
or cold, according to the necessities of the case — and a bath, 
even a warm bath will reduce the temperature if it be very- 
high. Tepid or cold baths may be administered to children 
in high fever, if requisite, but if cold the bath must be of 
short duration. A fall of temperature is set going by the 
immediate shock, not necessarily by prolonged immersion, 
and the latter is liable to induce a state of collapse and ex- 
haustion, such as is not often seen in adults. 

The tender skin of a child should always be a matter of 
attention. Poultices and hot bottles easily scald, and ban- 
dages are very liable to cut or excoriate if not carefully 
applied, and frequently readjusted. Poultices are in frequent 
use for cases of thoracic and abdominal disease. They 
should never be so hot as to be in any degree painful. But 
I discard them as much as possible. They soon become 
cold, hard, and uncomfortable, and they are often heavy. A 
warm fomentation, by means of spongio-piline, well covered 
in by cotton wool, is in every way preferable, at any rate, 
for diseases of the thorax. 

[A layer of cotton, covered with oiled silk, by condensing 
the insensible perspiration, and becoming moist, acts jn the 
same manner, and is preferable to a poultice, in both thoracic 
and abdominal diseases, since it does not require changing, 
and is always warm.] 



28 THE DISEASES OF CHILDREN. 



CHAPTER I. 

DENTITION. 

The milk teeth are cut in the following order : The two 
lower central incisors from the seventh to the ninth month, 
often later and sometimes earlier. After a lapse of five or 
six weeks come the two upper central incisors ; next come 
the two lower lateral incisors, followed by the upper 
lateral incisors. After an interval, the four front molars 
appear, followed again by the four canines, and last of all by 
the four posterior molars, the whole set being cut by about 
the end of the second year. [The following table shows in 
months, the usual times of appearance of the twenty milk 
teeth : 

Molars. Canine. Incisors. Canine. Molars. 

24-12 18 9-7-7-9 I iS I 12-24. 

The lower jaw is ordinarily a little in advance of the upper.] 
But it must not be supposed that there is any strict time- 
keeping in the appearance of the teeth, for, although there 
is a pretty definite order of occurrence, the lower central 
incisors may appear early or late, and the others may follow, 
sometimes several at once, sometimes with long intervals 
between them. It often happens that the four central incis- 
ors come, then follows an interval, and then steadily onwards 
come all the rest save the last four molars, the appearance 
of which may, even in healthy children, be deferred for three 
or four months over the average age of two years. 

Dentition is usually held to be the cause of many ailments, 
but to what extent it is really so is doubtful. The time of 
dentition is one of transition. A uniform and bland diet is 
changing for one of greater variety, and the febrile attacks — 



DENTITION. 29 

diarrhoea and vomiting, which are so rife at this time, are 
more satisfactorily explained by indigestibility of food than 
by some occult influence of tooth-cutting. This much, 
however, maybe allowed: that the growth of a child is one 
of stages; that there are periods during which unusual 
progress is made ; and that the period of dentition is one of 
these. Increased activity of all the physiological processes 
at work, necessarily implies greater risks of friction between 
one organ and another, or even of a regular break-down. 
Excessive energy, if not properly regulated or adequately 
expended, is liable to lead to an explosion of ^ome sort or 
another. Some such general hypothesis as this, must hold 
good for the instability of working which is common in all 
the viscera during the first dentition, and to a less extent 
during the second dentition, and in the years which usher in 
puberty. In this general sense, the time of dentition is, no 
doubt, a time of peril. The mortality is high, and disorders 
of many kinds — convulsions, bronchitis, pneumonia, diar- 
rhoea, etc. — each claims its victims. But this is not as a 
consequence of the eruption of the teeth, but as part of a 
general activity of growth and development, to which den- 
tition and morbid phenomena both in a sense respond. 

Still there are, no doubt, certain minor evils attending 
dentition, which require at least a mention. Some chil- 
dren are remarkably susceptible to "colds" under such 
circumstances — that is to say, as each tooth comes through 
the gums the child suffers from coryza; the eyes run, 
the nose also; there is much sneezing, and perhaps a 
little cough. There may be at the same tim£ pyrexia, and 
the bowels become irregular — now confined and now relaxed. 
Some get a sharp attack of fever (temp. 103 or 104 ), the lips 
and tongue becoming a bright red, the child becoming rest- 
less and fretful. Others have diarrhoea at these times ; 
others, again, have convulsions, and a still larger number 

3 



30 THE DISEASES OF CHILDREN. 

have threatenings of them in the form of wildness and ex- 
citement of manner, more irregularity of muscular move- 
ment than usual, temporary carpo-pedal contractions or 
strabismus. Most children have an excessive dribbling of 
saliva, are frequently biting anything they can put their 
hands to, and there may be a little superficial ulceration of 
the mouth. Indigestion is common. The child suffers 
from heartburn and offensive eructations, while lichen urti- 
catus (strophulus) appears upon the skin. Convulsions are 
not a common ailment of dentition, and it is the opinion of 
West, Henoch, and many other observers, that they are but 
seldom seen except in association with rickets. Those 
whose fits commenced with infantile convulsions, form, 
however, so large a proportion as seven per cent, of the 
whole number of epileptics. 

For the treatment of these varied conditions, to be fore- 
warned is to be forearmed, and the timely management of 
slight disorders in all probability arrests more serious evils. 
To control the excess and irregularity of muscular move- 
ment, is probably to avert the development of a pronounced 
convulsion. The " cold " neglected becomes a bronchitis 
or pneumonia; the indigestion leads to vomiting and diar- 
rhoea ; the slight feverishness to severe pyrexia. The treat- 
ment may seem somewhat empirical, nevertheless simple 
means suffice in most cases; carpo-pedal contractions and 
other threatenings of convulsion, will often speedily subside 
on the action of some mild aperient — a small dose of cal- 
omel, or a couple of grains of hydrarg. c. creta with a sim- 
ilar dose of p^ulvis rhei. The coryza is suitably treated by 
a little ammonia and ipecacuanha. The fever by a drop of 
tincture of aconite, or a little salicylate of sodium with ace- 
tate of ammonium (F. 2), and so on. 

If the pyrexia be severe, and there be any threatening of 
convulsions, and a tooth seems to be worrying the gum close 



DENTITION. 



31 



beneath the surface, there can be no harm in using the gum 
lancet to relieve the upward pressure ; at the same time 
bromide of potassium and some saline, such as citrate of 
potassium, should be given internally, either as a nocturnal 
draught or twice or three times a day. 

The second dentition commences about the seventh year, 
with the eruption of the first molars ; thence onward come 
the central and lateral incisors, the first bicuspid, the second 
bicuspid, the canines and second molars, at invervals of a 
year or so. . 

[The thirty-two permanent teeth are cut in the following 
order, the figures representing years : 

Molars. Bicuspids. Canine. Incisors. Canine. Bicuspids. Molars. 

25-I3-6 I IO-9 I II [ S-7-7-8 I II I 9-IO [ 6-13-25 I .] 

Some have thought that this also, is a time of hazard to 
the child, but there is less evidence of risk now than even 
during the first dentition ; nor is there, indeed, the same 
reason for the occurrence of any special disorders. There 
is no change of diet, no special development which begins 
at this time, at all comparable to that which takes place 
during the first dentition. It is a time when education 
begins in earnest, when growth in most cases is proceeding 
rapidly, and therefore a time when there are many risks, 
though probably in most cases independent of dentition. 
Dr. Gowers, from an analysis of a large number of cases of 
epilepsy, shows that the numbers rise at seven years of age 
— the commencement of the second dentition — and fall again 
in the next few years, preparatory to a further rise at puberty. 
Still it seems not unlikely that this should be referred to the 
extra calls which, at this time of life, are made in any case, 
upon brain and body, rather than to the process of dentition; 
and, apart from epilepsy, chorea, and neurotic diseases gen- 
erally, there are none which attach themselves peculiarly to 
this period. 



32 THE DISEASES OF CHILDREN. 

CHAPTER II. 

DIET OF CHILDREN IN HEALTH. 

The student often starts in practice with such limited no- 
tions on the subject of diet, that many a mother knows more 
of what is actually required than he does. True, indeed, 
the fundamental rule upon which all practice is founded, 
that the mother's milk, and that only, should form the 
infant's food for the first few months of life, is a choice stock 
in trade, but we soon find out how very limited, and often at 
fault is this statement of the matter. Many mothers cannot, 
many mothers will not, nurse their infants at all, and many 
more are so situated through the calls of society, or of busi- 
ness, that this, the chief of maternal duties, can only be 
fulfilled in part. Thus it early becomes a question for all of 
us, What is to be done under each or any of the circum- 
stances which this enforced neglect entails ? 

It will be well to attend to the following suggestions : 

The infant should be fed from its mother's breast, if not 
for the full period of lactation, at least as long as possible, 
and if not entirely, then partially — that is to say, the breast 
should supply at least one or two meals daily. 

If the mother be able to suckle it entirely, no other food 
is to be given to the infant. It is to be put to the breast 
every two hours for the first five or six weeks, between the 
hours of six a.m. and ten p.m., and afterwards the interval 
between the meals is to be lengthened gradually, till a three- 
hour interval is reached.* It is said that a healthy child 

* Should the mother be affected with either syphilis or advanced phthisis, 
this rule does not hold. — Ed. 



DIET OF CHILDREN IN HEALTH. 33 

will sleep all through the night hours, but in the first five or 
six weeks of life, it will require food several times during 
the night. Even when infants are some months old one 
meal in the middle of the night may be necessary, and to 
this there is but little objection. The digestion of a healthy 
infant is rapid, and, while it should not be allowed to have 
food too often, any lengthened fast is equally to be avoided. 
The interval between meals is to be strictly enforced for 
all infants that are healthy. Children are creatures of habit, 
and soon learn their proper meal-times. They will often, 
indeed, begin to cry punctually at the time. But they also 
are easily educated in faulty habits. It is the custom of 
many mothers to pacify crying at all times with the breast 
or the bottle — and a more pernicious practice it is impossible 
to conceive. The more the crying the more the feeding, and 
the more the feeding the more they cry, and what between 
crying and sucking the day and night are spent in misery. 
These are the cases which form the great majority of the 
thin, pining, pitiable mites who are brought to a hospital 
" for consumption of the bowels," but with bad feeding only 
to blame. And what wonder} if grown-up persons were to 
be always eating, who among us would not be dyspeptic, 
and who would not be quite as miserable, if less demonstra- 
tive than the infant ! Now let it be remembered that there 
are many children who in the first week or two of life, when 
the stomach is, as it were, unfolding to its duties, cry a good 
deal. They are a source of great discomfort and pajn in a 
household — sucking at something will almost certainly quiet 
them, and other methods of treatment, food, doctoring, and 
so forth, often fail. It is very important in such cases to 
impress upon the mother and nurse that if they quiet a child 
by this means, they are but sowing the wind to reap an in- 
evitable whirlwind. If they bear with it for a short time the 
child soon becomes accustomed to the habits enforced; it 



34 THE DISEASES OF CHILDREN'. 

must sleep after a while, and the first lesson of its life is 
learned. Whenever there is much crying, however, attention 
should be directed to the quality of the milk. It may be 
poor in quality or deficient in quantity, and the child cries 
because its stomach is full of flatus. Sometimes, again, it is 
over-plentiful, and the child taking it too greedily is troubled 
in consequence with colic. [This latter trouble can be pre- 
vented, should the milk flow too freely, by slight pressure 
by a finger above and below the nipple.] 

If it be necessary to make any addition to the breast 
milk, good cow's milk* may be tried first, and it is to be 
diluted with an equal part of water, or equal parts of milk 
and lime-water slightly sweetened with sugar of milk or 
lump sugar, six tablespoonfuls to be given at a meal. The 
breast may be given night and morning, and the milk and 
lime-water in the meantime, or the two may be made to 
alternate. The milk may be boiled in hot weather, or if it 
disagree; and to one or two of the meals in the day, some- 
times to all of them, a good teaspoonful of cream should be 
added. The mixture of milk and lime-water is not by any 
means always suitable. In some cases, where the milk is 
still too much for the child, and is most of it vomited in 
large curds, it may be further diluted. In others, where it 
appears to lead to flatulence and abdominal pain, a mixture 
with thin barley-water will be found to agree better. Barley- 
water has also the advantage of acting as a gentle laxative, 
a very valuable property, inasmuch as many children fed 
upon cow's milk and water, or cow's milk and lime-water, 
are much troubled with constipation, the motions being very 
large, lumpy and hard. Barley-water acts most beneficially 
in many such cases, but its use is to be watched, as infants 

* Cow's milk should be faintly acid or neutral; of sp. gr. 1026 to 1030 ; 
and should contain an amount of cream which is variously stated by different 
writers to be from 5 to 10, or even 14 per cent. 



DIET OF CHILDREN IN HEALTH. 35 

are very sensitive to the administration of starch in any 
form, and I have repeatedly known an eczematous eruption 
to appear upon the buttocks after only one or two meals of 
milk treated in this way. In very young infants the mixture 
of milk and water, or milk and lime-water, may be attended 
with vomiting or with abdominal pain. In such cases the 
milk must be diluted till it forms only a third part of the 
whole, equal parts of milk, water, and lime-water being given, 
sweetened as before with milk sugar. But there are many 
cases where this fails to secure the child's health and com- 
fort. It is griped with pain after each meal, and it remains 
thin, while the motions are still pale and lumpy, often con- 
taining undigested curd. It is probable that, under these 
circumstances, the curd of the cow's milk, which is larger 
and firmer than that of the mother's milk, is the element at 
fault, and barley-water will often remedy this. By mixing 
it with the milk the casein curdles in a state of more minute 
subdivision, and more closely resembles the thin, small 
flocculent curd of human milk. Meigs and Pepper advise 
a little arrowroot in addition. Thin gelatin jelly, a teaspoon- 
ful to half a pint of milk and water, may be mixed with the 
milk instead of the barley-water, for the same purpose. 
Some Infant's Foods may be used for the same purpose 
also. These are, for the most part, combinations of farina- 
ceous food in which the starch has been converted into 
dextrine and grape sugar by the mode of preparation. In 
this state they are easy of digestion, and may, therefore, 
with due care, be used to thicken the milk. Starch, which 
has undergone no such changes, is unsuitable, because in the 
first three months of life the salivary and pancreatic juices 
are wanting, and consequently there are no facilities for its 
digestion. Mellin's food, Liebig's infant food,* Nestle's 

* See foot-note, p. 39. 



36 THE DISEASES OF CHILDREN. 

food, Savory & Moore's food, and others, are all useful in 
certain cases. Sometimes one will suit, sometimes another. 
The proper one for a particular case must always be some- 
what a matter of experiment. A teaspoonful is added to 
each meal. Nestle's food requires boiling. Condensed milk 
of some good brand is often useful at this period of life, and 
many infants thrive well upon it. It possesses some advan- 
tages, chief of which is its freedom from any tendency to 
turn sour. Care must be taken not to give too much of it. 
A small teaspoonful to a teacupful of water is quite sufficient 
for a meal, and after two or three months it should, in most 
cases, be replaced by cow's milk, or combined with some 
infant's food. [Condensed milk possesses the advantages of 
keeping the bowels open, and making very fat, hearty-look- 
ing babies. The disadvantages are, that it gives little 
strength to resist disease, and infants fed upon it cut their 
teeth late, and otherwise show the symptoms of a moderate 
rachitic tendency.] 

As regards quantity, it has been estimated that the mother 
supplies to her baby a pint of milk in the twenty-four hours 
in the first week or two, and that this quantity gradually 
increases until in the later months of lactation about three 
pints is reached. Some such quantity, therefore, distributed 
over regular intervals, should be the daily allowance to a 
child from birth onwards. But infants vary much in respect 
of the quantity which they will digest. Some are habitually 
small feeders. Therefore, provided that the child grows, 
that its flesh is firm, and it is happy, there should be no 
absolute insistance upon a minimum of two pints. [The 
quantity is rather large. The average, according to J. Lewis 
Smith, for children under five weeks being about 12.5 fluid 
ounces in the twenty-four hours. This average is about 
doubled between the first month and the first year.] 

In some cases, notwithstanding all the care and skill that 



DIET OF CHILDREN IN HEALTH. 37 

are lavished upon them, cow's milk cannot be digested. Till 
lately, goat's milk or asses' milk has been resorted to, either 
of which resembles the human milk more nearly in its 
poorness of curd. They may be given either undiluted or 
diluted — as in the case of cow t 's milk — with water or 
lime-water, or even diluted with barley-water. Whey, with 
a tablespoonful of cream added to each meal, is another very 
useful food when milk disagrees; and, of late, two other 
valuable additions have been made to an infant's dietary in 
peptonized milk and artificial human milk. The directions 
for making these are given in the Appendix of Formulae. 
One other food still requires mention, that which goes by 
the name of " strippings.'' All infants digest cream w r ith 
facility ; the curd, on the other hand, is with all an obstacle. 
Strippings, obtained by remilking the cow after its usual 
supply is withdrawn, is rich in cream and poor in curd, and 
consequently has much to recommend it as an infant's food. - 
Dr. Eustace Smith commends it highly, diluted with water or 
barley-water, in cases where other combinations are assimi- 
lated with difficulty. 

As a last resource a wet-nurse must be obtained. In 
selecting her attention should of course be paid to her 
appearance and state of health. Inquiries should be made 
for any previous symptoms indicative of syphilis ; the skin 
and throat should be examined for scars, etc. It may per- 
haps be advisable that, where there is a choice, a nurse should 
be chosen of similar complexion to the infant. The state of 
the breasts must be examined, their distension, the state of 
the nipples, and the quantity and quality of the milk. It is 
well, too, to be prepared with a second nurse, as the first 
selection may after all fail in some way or another. Infants, 
as w r ell as their parents, have unaccountable likes and 
dislikes. 

[In selecting a wet-nurse one who has previously suckled 

4 



38 THE DISEASES OF CHILDREN. 

an infant, but who is yet young and robust, and whose child 
is of nearly the same age as the one to be nursed, should 
be chosen. The slightest tendency to phthisis is cause for 
rejection. A woman of violent or quick temper should not 
be engaged. The character of the breasts and milk are also 
to be considered. Blondes make better nurses than bru- 
nettes. The nipples then will be rose-colored, and should 
be prominent. The breast need not be large, but should 
show large veins, marbling the skin. The milk of a healthy 
woman is of a bluish-white or pure white color. It should 
be examined in reference, 1st, to its reaction; 2d, its specific 
gravity; 3d, to the amount of cream. The reaction should 
be neutral or slightly alkaline; the specific gravity 1030 
to 1032. The cream should be in the proportion of 3 per 
cent.] 

While upon this subject, however, it may be as well to 
say that in my opinion — so long as we have to do with chil- 
dren who have not persistently wasted for some time — care- 
ful artificial feeding will seldom fail. This is the more to be 
insisted upon both as a hope, and as a motive for persever- 
ance, since wet nurses are in many families — perhaps in 
most — an impossibility. They are difficult to get at the 
proper time ; they are a considerable expense ; they intro- 
duce a sudden and dominant influence into a household, for 
which it finds itself unprepared — not to mention the moral 
considerations, which cannot be altogether ignored — so that 
it generally comes to be a question of what artificial food is 
the best. 

Suppose now that by the aid of one or more of these 
suggestions the infant has safely reached the age of eight 
months, the time arrives for some addition to its diet. In 
the case of a child fed entirely upon the breast milk, two 
meals a day of cows' milk should now be introduced, a tea- 
cupful at each meal. Should any discomfort be experienced 



DIET OF CHILDREN IN HEALTH. 39 

after them it may generally be remedied by boiling the milk 
or by the addition of a third or fourth part of lime-water — 
a r ter three or four weeks — first to one, and then to two meals 
daily, one of the many infants' foods is to be added. Nestle's 
food, Liebig's* or Mellin's agree well with most children — 
a teaspoonful is to be well mixed with a teacupful of hot 
milk. Nestle's food should be boiled with the milk. The 
food may be varied by, or alternate with, Chapman's entire 
wheaten flour. This form is more suitable than white 
bakers' flour, because it contains the pollard or outer part 
of the grain of wheat, and this is rich in nitrogenous matter, 
fat and salts, and also in the cerealine, which exercises a 
diastatic action upon the starch, turning it into sugar. 

The finest dressed white flour contains less nitrogen and 
more starch, and is therefore less wholesome, for reasons 
previously stated. The entire flour needs prolonged boiling 
for its preparation in order to break up its starch and convert 
it into dextrine or grape sugar. This may be done by put- 
ting it into a basin, tying it over with a cloth, and then 
immersing the whole in a saucepan of boiling water for 
some hours; or, by tying it up tightly in a pudding-cloth 
and boiling. Eustace Smith orders a pound to be heated 
thus for ten hours, and then removed, the outer soft part to 
be cut away, and the inner hard part grated and used as meal 

* The following directions are given by Dr. Pavy for the home preparation 
of Liebig's food : Take half an ounce of wheat flour, half an ounce of malt 
flour, and seven and a quarter grains of the crystallized bicarbonate of potash, 
and after well mixing them add one ounce of water, and lastly, five ounces of 
cow's milk. Warm the mixture, continually stirring, over a very slow fire 
till it becomes thick. Then remove the vessel from the fire, stir again for five 
minutes, put it back on the fire, take it off as soon as it gets thick, and finally 
let it boil well. It is necessary that the food should form a thin and sweet 
liquid previous to its final boiling. Strain before use to separate the fragments 
of husks. Barley malt is to be used, and a common coffee-mill will grind it 
into flour, which is to be cleared from the husk by a coarse sieve. — Pavy on 
M Food and Dietetics," second edition, p. 192. 



40 THE DISEASES OF CHILDREN. 

— a teaspoonful at a time, well mixed with cold milk, to 
which a quarter of a pint of hot milk is added before serv- 
ing. 

Should the child have already taken to artificial feeding, 
according to the rules laid down, all that will be necessary 
at seven or eight months, will be to increase the quantity of 
milk and food which has already by experience been found 
to suit the particular case. 

After nine months old, further variety may be introduced. 
A cup of beef-tea; or, mutton, chicken, or veal, broth; or 
the yelk of an egg should be given occasionally. All these 
things are, however, only accessories to the main article of 
diet — i.e., good milk, of which a healthy child should con- 
sume a pint and a half or two pints daily. At this time of 
life it should have five meals during the day, thus : At eight 
a.m., a teacupful of warm milk thickened with a teaspoonful 
of Nestle's food, or entire flour. At eleven a.m., a break- 
fast-cupful of warm milk, or the yelk of an egg well beaten 
up in a teacupful of milk, or a teacupful of veal broth or 
beef-tea. At two p.m., a breakfast-cupful of warm milk. 
At six p.m., a teacupful of milk with a teaspoonful of Nestle's 
food or baked flour. At eleven p.m., a teacupful of warm 
milk. If the child sleeps through the night, well and good. 
But there is no objection to a night meal of a teacupful of 
milk about three a.m., if it be wakeful. 

At a year old the breakfast may consist of a teacupful of 
milk, a slice of bread and butter, and the yelk of an egg 
lightly boiled. At eleven, a teacupful of rnilk and a rusk. 
At two, a teacupful of broth or beef-tea with a little bread. 
And at six, a breakfast-cupful of milk, with bread and but- 
ter. The meals may be varied by substituting a teaspoon- 
ful of oatmeal, well boiled, in a breakfast- cupful of milk; 
or bread and milk for the egg at breakfast; and a table- 
spoonful of custard pudding may be added to the dinner. 



DIET OF CHILDREN IN HEALTH. 4 1 

The child may next have a little well-mashed potato, or 
well-cooked cauliflower or broccoli added to its dinner — a 
tablespoonful well soaked in gravy. 

After eighteen months, or when the double teeth begin to 
appear, it may begin with meat, and the meal-times may be 
somewhat altered. At eight a.m. breakfast, a breakfast- cup- 
ful of bread and milk or milk with thin bread and butter 
and the yelk of an egg lightly boiled. Thin porridge may 
be substituted on some days. A drink of milk with a rusk 
may be given if necessary during the morning. At half-past 
one dinner, a tablespoonful of pounded mutton, with some 
mashed potato and gravy, or a cup of beef-tea in which 
some vegetable has been stewed, and a little toast and water 
to drink. At five, a breakfast-cupful of milk, thin bread and 
butter, and stale sponge-cake. No other meal will be 
necessary, but a little milk may be at hand in case of need. 

After two years meat may be given daily, and fine minc- 
ing may be substituted for pounding. Light farinaceous 
pudding may also constitute part of the daily mid-day meal; 
the other meals remaining as before. 

I have often been asked, in the case of older children, to 
draw out a diet table, but it is quite unnecessary. All chil- 
dren should have plenty of milk, and bread and butter for 
breakfast and tea ; and roast or boiled meat with gravy and 
light vegetables for dinner, with some light farinaceous and 
egg pudding well sweetened. With regard to quantity, the 
only rule I would enforce is this — let some reliable person 
be always present at meal-times to see that the food is taken 
leisurely, and properly masticated, and if this is done I 
believe that very few children will take too much. Some 
children require more than others, but, if the meals are not 
hurried, the healthy appetite is satisfied at the proper time 
and is a far better indicator than any arbitrary rule can ever 
be. Food-bolters are the children that get into trouble from 



42 THE DISEASES OF CHILDREN. 

over-feeding. They steal a march upon their stomachs, and 
before they feel satisfied they have taken too much. For 
such, the old adage to leave off with an appetite is needful, 
but it is not the teaching of physiology. In the same way 
with children's likes and dislikes ; if the rule given above 
be observed, what a healthy child likes it will usually digest, 
what it dislikes will disagree. I am of course assuming that 
its experience lies well within the range of wholesome arti- 
cles of diet. Take the case of fats and sugar, for instance. 
Nearly all children dislike fat, and are equally fond of sugar. 
It is an unquestionable fact that rich articles of food easily 
upset them; what, therefore, can be the sense of insisting on 
children eating fat ? The liking for it comes at the proper 
time. On the other hand, children are fond of sugar, and 
make up with it where they fail in fat, and there is no evidence 
whatever that sugar is harmful when taken at proper times. 
To take sweets at all hours of the day at the expense of the 
proper meals is one thing, and to be strictly forbidden ; the 
moderate consumption of saccharine material at meal-times, 
whether it be in the form of sugar or good wholesome pre- 
serve, is quite another thing, and as certainly to be recom- 
mended. 

No doubt there are some children the functions of whose 
stomachs seem to be topsy-turvy. Everything they ought 
to like disagrees with them, and they live — 1 will not say 
thrive — upon most unwholesome diet. Some will be almost 
entirely carnivorous, some cannot take milk, others resent 
farinaceous puddings, and so on. But it will generally be 
found that where this is so the early education of the 
stomach has been at fault, and patient correction will bring 
it round. Mothers and nurses will say a child cannot take 
this and that, because they have administered the thing im- 
properly. But if the medical man insists on a return to such 
diet under strictly detailed conditions — nay, sometimes it 



DIET OF CHILDREN IN HEALTH. 43 

may be necessary to make it one's business to see a child at 
its meals, and what it is eating — no difficulty whatever will 
be experienced in its digestion. 

One or two points concerning the administration of food 
to infants may be alluded to here, as akin to the question of 
diet, and upon which the success of all diets depends. 

In the first place it is necessary to insist upon the observa- 
tion of the most scrupulous cleanliness. No one would 
believe, without actual experience, how difficult it is to keep 
a feeding-bottle and its tube sweet. But so difficult is it, 
even with the greatest care and the closest supervision, 
that it is advisable to simplify the apparatus as much as 
possible. For this reason I discard bottles for habitual use, 
the food being placed in a cup or other w r ide-mouthed recep- 
tacle. From this it is taken by black rubber tubing of yfc 
inch bore, with a nipple fitted on to the end by one of the 
simple earthenware joints in common use. The tube and 
nipple are to be separated after each meal, and kept in a 
weak solution of salicylate of sodium gr. iv ad §j of water,* 
and to be replaced by new ones directly there is anything 
unpleasant about either when placed close to the nose — a 
test which is to be frequently applied by the doctor himself. 
Small brushes are usually sold with the bottles for cleansing 
purposes, but as regards the tubes it is safer to proceed upon 
the assumption that they cannot be thoroughly cleansed by 
this or any other means, and to provide new ones at frequent 
intervals. Similarly all joints and valves are to be eschewed ; 
they fulfil, no doubt, their immediate purpose by preventing 
reflux of the milk, and so keeping the tube full, but they are 
of very little use at any time, and even the simplest of them, 
made as they are of metal, are impossible to clean, and emit 
an unpleasant odor after very little use. The feeding-bottle 

* A valuable suggestion made by Dr. Lewis Marshall of Nottingham. 



44 THE DISEASES OF CHILDREN. 

which best fulfils these conditions is one invented by Mr. 
Day, of the Royal Hospital for Children and Women, 
Waterloo Road ; in it all joints are done away with, and a 
small vent is made in the bottle to secure ease of suction. 
This bottle is as near perfection as any such contrivances 
can be; but even superior to it, in my opinion, is the old- 
fashioned slipper, with its simple india-rubber nipple — for 
there is no tube to be cleaned, and it necessitates the con- 
stant attention of a nurse during the meal. No child should 
be left to take its meal as it wills. Some infants are invet- 
erate bolters, and will consume a bottle of milk in three 
minutes, which should take them at least ten. The rate of 
supply must be controlled by the nurse, otherwise vomiting 
and colic will result. 

[Tubes should never be used. They cannot be kept 
clean any length of time, even when the greatest care be 
exercised, and, when slightly neglected, as is too frequently 
the case, are often the cause of digestive troubles. 

The bottle and nipple are much to be preferred. Of these 
there should be two each. The nipples should be soft and 
flexible, of a conical, not bulbous, shape so that they maybe 
easily everted. After each nursing the nipple must be 
immediately removed from the bottle, cleansed externally by 
rubbing with a stiff brush wet with cold water, and then 
everted and treated in the same way. It must then be placed 
in cold water and allowed to stand in a cool place until 
the following nursing. 

The bottle for an infant under three months ought to have 
a capacity of four to six fluid ounces and be of flint glass. 
Immediately after using, it must be scalded and cleaned 
with a brush. It should then be filled with a solution of 
one of the salts — bicarbonate or salicylate — of sodium and 
allowed to stand until next required. It should then be 
thoroughly rinsed with cold water.] 



DIET OF CHILDREN IN HEALTH. 45 

Of food warming and food preservation it may suffice to 
say that of all food warmers Grout's is the simplest and the 
best. It consists of a well, sunk in a cubical hot water tin, 
and in it food or water can be kept at a comfortable heat all 
night, without any supervision whatever. But like all appa- 
tus of this kind it is a good incubator ', and food placed in it 
may become sour. The best plan to adopt, perhaps, is to 
keep the water hot by this means, and to add the water to 
the milk at the time of its consumption. 

It may be sometimes necessary to preserve milk for some 
hours for a journey, etc. The best plan for carrying out 
such an object is to fill soda-water bottles with boiling milk, 
and immediately to cork them tightly. 

[Condensed milk is here of the greatest value. In travel- 
ling either by cars or by steamboat, hot water can easily be 
obtained, so that the child has the advantage of the same 
quality of food from the beginning to the end of its jour- 
ney.] 



46 THE DISEASES OF CHILDREN. 



CHAPTER III. 

DIET DISEASES: ATROPHY— FLATULENCE— COLIC— CONSTIPATION. 

The consideration of the diet fit for a healthy infant up 
to the period when it can, with certain limitations, take food 
in common with its parents, leads on naturally to the con- 
sideration of those diseases which are dependent upon 
imperfections in the diet, whether of quantity or quality, 
and to the treatment which is most efficacious for their 
cure. 

These diseases are both numerous and important, whilst 
their heterogeneity involves us in some difficulties of arrange- 
ment. Perhaps the best plan that can be adopted is to take 
them in the order in which they seem to arrange themselves: 
I . Simple wasting ; 2. Diseases of the digestive tract, includ- 
ing colic, flatulence, constipation, diarrhoea, vomiting, indi- 
gestion, or gastric fever, and stomatitis. There are other 
diseases which are also diet diseases, such as rickets and 
certain of the diseases of the skin ; but it is more conve- 
nient to consider these at a later period. 

Simple wasting or atrophy is due to insufficient or im- 
proper food. If the food is bad — and by that I mean indi- 
gestible — the wasting is generally associated with symptoms 
of intestinal disorder, which may be best treated under the 
head of diarrhoea, colic, and so on. Naturally enough the 
two conditions, insufficiency and indigestibility, are com- 
monly associated in practice. 

Nevertheless, it is well to remember that amongst the 
number of infants who require dietetic treatment, the total 
number of cases due to simple starvation is not inconsider- 



DIET DISEASES I ATROPHY — FLATULENCE COLIC, ETC. 47 

able. The diagnosis must, for the most part, be arrived at 
from the absence of symptoms indicative of any local disease. 
The infant does not get on, or gradually loses the plump- 
ness it has gained, becomes pale and thin and is always cry- 
ing. Still it fails to attract notice by any definite signs of 
illness ; on the contrary, it is not unusually bright looking 
and intelligent, it is easily attracted and pacified for the 
moment, doubtless solaced with the hope of the coming 
meal which is to bring freedom from its pangs. These 
children are pale, sharp featured, the fontanelle depressed, 
the arms and legs and buttocks thin, the muscles flabby, and 
the skin cool and moist. They are always crying, the cry 
being noisy and passionate, and in the best-marked instances 
alternates with vigorous sucking at anything within reach, 
sometimes at the thumbs till they are raw. The meals "are 
taken ravenously, and as soon as they are finished, or in the 
intervals of the sucking, crying is repeated, or in very young 
infants, from the absence of that pleasurable stimulus which 
should be conveyed by suitable food, the child dozes at its 
meals. In the worst cases, when exhaustion is extreme, it 
may even be persistently drowsy. The viscera must be 
carefully examined in every case, and should show no sign 
of disease. [Besides the above-mentioned symptom we find 
that the child takes little or no notice of what is going on 
about him, but from time to time moves his head restlessly 
on the pillow, and mutters low, fretful moans. This condi- 
tion may proceed to stupor. There is general hyperaesthesia, 
so that the least movement causes whimpering. The eyes 
become sunken, and the fontanelle depressed. The abdomen 
is soft and generally natural in shape. There is most fre- 
quently a tendency to diarrhoea. The pulse is compressible.] 
But inasmuch as even very young infants are not exempt 
from insidious complaints such as empyema, or broncho- 
pneumonia, and wasting may be their only noticeable sign, 



48 THE DISEASES OF CHILDREN. 

the diagnosis cannot be reliable until a thorough examina- 
tion has been made. To take one example out of many, a 
child of eight months old was brought to the Evelina Hos- 
pital, for wasting. It had been fed upon bread and milk 
since the age of eight weeks. No wonder it had always 
been thin and lately had got thinner ! The bowels acted 
regularly and there was nothing about the face to indicate 
local disease, and without examination it might readily have 
passed for a case of atrophy from bad feeding. It lay in its 
mother's lap in a passive condition, and the mother had in 
fact become concerned about it, because the wasting had 
now gone to that extent that sitting up seemed a trouble to 
it. An examination of the chest revealed the existence of 
extensive broncho-pneumonia, which had not even been 
suspected. The chest was dull over the base of the lung 
on both sides; tubular breathing extended up to the spine 
of the scapula on the one side, associated with bronchophony, 
and on the other was audible in patches, with much brdn- 
chitic crepitation in the larger tubes. 

Treatment. — A careful attention to the rules laid down 
for dieting healthy infants will in most cases prove successful. 
Inasmuch as the child has usually been improperly fed, it is 
generally advisable to give a few doses of some mild aperient, 
and none is better than castor oil, which, sweetened with 
sugar, most infants take readily. It may be given as a mix- 
ture twice or three times a day (F. 3), a mode of adminis- 
tration which I prefer ; or as a single larger dose of half a 
drachm to a drachm. 

Insufficient food must of course be met by increasing its 
quantity, but caution is necessary in doing this. The 
stomach of an infant who has been persistently starved for 
some weeks, or even months, will not tolerate an immediate 
return to the quantity of food which would be suitable for a 
child of its age under natural conditions. The increase is 



DIET DISEASES: ATROPHY FLATULENCE — COLIC, ETC. 49 

to be made by stages ; if not, the stomach, which is an 
organ which in early life is most punctilious in resenting 
any sudden departure from its recognized custom, will cer- 
tainly relieve itself by vomiting. An infant which has been 
taking perhaps half a pint of milk in the twenty-four hours 
with bread, and so forth, may have half a pint of milk sub- 
stituted for the bread, and the pint is to be day by day 
slowly increased till the proper quantity (two to three pints) 
is reached. Nor is it uncommon for such children to re- 
quire an amount of dilution of the milk out of proportion 
to their age. Educated upon faulty principles as it has been, 
the stomach adheres to them with pertinacity, or becomes so 
irritable that even proper feeding does not seem to suit, and 
the child can only be saved by the most patient and attentive, 
even quick-witted, regulation of its diet. Use what care we 
may, whenever a child has continuously wasted for some 
weeks, the prognosis must be doubtful until it has begun to 
mend under the treatment adopted. 

Such cases indeed, but for the objections, often insuper- 
able, which have already been alluded to, should always be 
wet-nursed. When this is not possible, cow's milk prepared 
in such a way as to be as nearly like human milk as may be* 
is to be given ; or failing this, some one of the other foods 
which have been mentioned in the previous chapter. For 



* Dr. Arthur V. Meigs, who has made careful analyses of human milk and 
cow's milk, gives the following directions for the preparation of the latter so 
as to resemble most nearly the former. Seventeen and three-quarters drachms 
of pure milk-sugar are to be dissolved in a pint of hot water. This should be 
kept in a cool place, as it is apt to sour in hot weather. When the child is to 
be fed, the nurse should mix together two tablespoonfuls of cream, one of 
milk, two of lime-water, and three of the milk-sugar solution ; when the 
whole has been warmed, it is ready for use. This quantity, at a feeding, will 
satisfy a healthy infant for the first few weeks, after which it is necessary to 
double the quantity of each ingredient. The milk and cream should be such 
as are ordinarily obtained in large cities, and not rich Jersey milk or cream. 
—Ed. 



50 THE DISEASES OF CHILDREN. 

the worst cases still further departures may be requisite. 
Whey, with a tablespoonful of cream added to it, will suit 
some ; whey and barley-water, or barley-water and cream, 
others. Sometimes artificially digested milk, or peptonized 
milk as it is now called, may be necessary ; sometimes a 
little beef juice. Any one of these, with or without a little 
alcohol, may in one case or another enable the child to turn 
the corner, and when this is effected, a more natural diet can 
be gradually resumed. 

Flatulence and Colic are amongst the most frequent 
digestive disorders in infancy. They are so commonly 
associated that it is unnecessary to discuss their separate 
symptoms. Flatulent colic is recognized in most cases by its 
relation to meals. Soon after food a child becomes restless, 
kicks its legs about, begins to grunt, and then perhaps utters 
a piercing, or sometimes a prolonged and harsh cry. At 
the same time its stomach is rigid, its face turns pale, and 
after a time eructations take place, and perhaps some vomit- 
ing of curd. As digestion proceeds the pain ceases. The 
physics of flatulence are not easy of elucidation, but the con- 
dition is associated either with poorness or small quantity of 
milk on the part of the mother — when it is reasonable to 
suppose that it is due to emptiness of the stomach — or with 
indigestible food. It is frequent where cow's milk is given, 
and in that case is due to the formation of firm curd in the 
stomach, and ceases as soon as the curd is disposed of either 
by vomiting or the process of digestion. If it persist, 
speaking generally, it indicates that the stomach is still 
empty, or that the meal remains undigested. It is often 
associated with, and aggravated by, irregularity of the 
bowels ; constipation being usual, with an occasional attack 
of diarrhoea. Where the bowels are constipated the motions 
are pale, lumpy, often very large and hard. They are evacu- 
ated with much straining, accompanied by a little blood, 






DIET DISEASES : ATROPHY — FLATULENCE — COLIC, ETC. 5 I 



which comes from the lower end of the bowel, and is due to 
the abnormal consistence and size of the motion and to the 
straining necessary for its evacuation. 

Some infants appear to be hyper-sensitive to the contact 
of food with the mucous membrane of the stomach and in- 
testine, and, even though it be in all respects proper, flatu- 
lence and griping are excited. Others there are whose 
bowels are from the first sluggish and prone to constipation. 
It is by no means an uninteresting subject for study, how 
far such idiosyncrasies foreshadow the temperament of after- 
life — the nervous or phlegmatic, for example ; but apart from 
this, it is no more than might be expected that in the first 
few weeks or months of infant life — when the stomach and 
intestine are called upon to perform functions to which they 
have hitherto been unaccustomed, and when they have no 
more than the transmitted capacity for their performance to 
rely upon — the functions should be performed less regularly 
and perfectly than afterwards, when they have become 
stereotyped and easy by training. 

And if this be the true way to regard the often recurring 
improprieties of function met with in infantile disorders of 
the digestive system, a rational mode of treatment recom- 
mends itself spontaneously. The details as applied to any 
particular case may require some skill in their application, 
and may even fail ; but the principles upon which they must 
be based admit of the clearest insight. For example, when 
dependent upon the want of training, flatulence and colic 
are best treated by carminatives ; in such case, stomachic 
stimulants, or charmers away of flatulence, possess a perfectly 
rational basis of action which their title does not suggest. 
A stimulant applied to the stomach when it is already strug- 
gling with a meal which it knows not how to dispose of, is 
not unlikely to make matters worse ; unless it should pro- 
voke vomiting, which is by no means a desirable issue in 



52 THE DISEASES OF CHILDREN. 

such cases. The drugs which are successful in so many 
cases as to warrant the name carminatives, are all impreg- 
nated with some volatile oil of strong flavor, and impart a 
sense of warmth to the nerve filaments to which they are 
applied. Afferent nerves, when employed in conducting 
any powerful impression, are for the most part so fully 
occupied as to be incapable of attending to other weaker 
excitors, and the stronger stimulant will at anytime displace 
the weaker. In flatulent colic some dill, fennel, or cinna- 
mon water is given ; the attention of the nerve filaments is 
attracted by its diffusibility and pungency, and diverted 
from the food. Time is thus allowed for the gastric juice 
to act and for digestion to proceed. In due course the irri- 
tating matters are broken up and disposed of; and the pain 
ceases till the next meal. Any of the aromatic waters may 
be given, though perhaps the aqua anethi* is in most re- 
quest. A tablespoonful or more is to be put into each 
bottle of food, or a similar quantity — sweetened with a little 
powdered white sugar — may be given afterwards. 

The Flatulence of Emptiness. — If the flatulence be due 
to the poorness of the milk — which must be ascertained by 
an examination of the mother's breasts — it may be remedied 
by feeding the infant during the day, and putting it to the 
breast only night and morning ; and if with this reduction 
there is still but a scanty meal for the child, hand-rearing 
must be taken to altogether. 

The flatulent colic of indigestible food may be prevented 
by further dilution of the milk ; by the addition of an alkali, 
such as lime-water or bicarbonate of sodium; or by the 
addition of barley-water or gelatine. Those things which 
tend to thicken the food slightly are most successful, prob- 



f Aqua anethi closely resembles in taste and properties Aqua Anisi U. S. P. 
—Ed. 






DIET DISEASES: ATROPHY — FLATULENCE — COLIC, ETC. 53 



ably, as Dr. Eustace Smith states, by preventing the forma- 
tion of large masses of curd. 

When the pain is very severe the colic may be relieved 
by warming the feet ; by a warm linseed-meal poultice to 
the abdomen ; by twenty or thirty drops of brandy in a 
little warm milk-and-water ; sometimes by a teaspoonful of 
aqua chloroform!. Where there is any suspicion of the 
retention of irritating material in the intestine, some castor- 
oil must be given. This may usually be prescribed after 
the formula already given (F. 3), but if it be also accom- 
panied by griping, it may be associated with a minute dose 
of opium, three drops of the tincture in a three-ounce mix- 
ture, a drachm to be given twice or three times a day (F. 4) 
to a child of nine months to a year old. If the collapse be 
severe, the bowels should be evacuated at once by an enema 
— the child being well wrapped in blankets the while. In 
all cases of flatulent colic it is essential to see that the child 
is kept warm. It is not only neccessary to encase the legs 
and abdomen in flannel, but to see that the wraps are 
retained in position. It often happens that a flannel binder 
is put upon the abdomen, and sewn on, as it is thought, 
securely. It quickly slips up, and the abdomen is left quite 
uncovered, as may easily be proved by putting the hand 
under the clothes of half a dozen babies consecutively. 
Again, the feet are wrapped in worsted socks, and are 
allowed to get wet with urine; so that whilst having the 
semblance of being cared for, appearances are belied by 
facts. The clothing of infants is adapted for the most part 
to the exigencies of urination, etc. They are so constantly 
wet, that anything elaborate in the way of clothing for the 
loins and Jegs is less convenient than the time-honored 
napkin. Hence it comes that while the thorax is well 
clothed in four or five layers of raiment, the abdomen and 
legs are practically naked — save for such melancholy pro- 

5 



54 • THE DISEASES OF CHILDREN. 

tection as is afforded them by some overhanging petticoat. 
But the lower part of the body requires as much care as 
the upper. It is as sensitive to chills and as liable as other 
parts to receive and promulgate harmful impressions. There- 
fore, when long clothes are discarded they should be re- 
placed by a pair of loose flannel drawers, such as can be 
fixed to the wraps, covering the chest, and will go outside 
the necessary napkins, being tied loosely either over or 
under the socks at the ankles. Dr. Lewis Marshall, of 
Nottingham, has combated the objections to the usual 
underclothing of infants by a special knitted jersey, admir- 
ably adapted to its purpose, and which it may be hoped will 
in time displace the flannel hitherto in vogue. 

Constipation may be due to malformation about the anus, 
more frequently to fissure, but most frequently, of course, of 
all to something amiss either in the tonicity of the bowel, 
the material it contains, or both. It is with the last group 
of cases that we are here concerned. The faeces are almost 
always paler than normal, or even gray like those of jaun- 
dice. Constipation may prove troublesome even from birth, 
and I have notes of several cases where the bowels acted 
only every seven or eight days for some weeks. Some rec- 
ommend that when this is the case the suckling should be 
treated through the mother. But this is a plan which is 
neither pleasant for her, nor very successful in overcoming 
the constipation. If it be desirable to treat the case so, a 
seidlitz powder may be given, or some Carlsbad salts, or 
two drachms of bitartrate of potassium may be dissolved in 
barley-water, flavored and sweetened, and taken as a drink 
during the day. For the infant castor-oil (F. 3) is as good 
a medicine as any. Sometimes a little fluid magnesia twice 
or three times a day answers the purpose, or five grains of 
the sulphate of magnesium dissolved in syrup of ginger and 






DIET DISEASES: ATROPHY FLATULENCE — COLIC, ETC. 55 

dill water (F. 5). Manna may be given (F. 6), or a powder 
of two grains of rhubarb and three of soda every night. 

[Some of these remedies have but a temporary effect, and 
may even, by their secondary action, increase the tendency to 
constipation. The following prescriptions are better: 

JJ. Mannre Opt., 

Magnesii Carb., aa.^j. 

Ext. Sennae Fid., f^iij . 

Syr. Zingiberis, fgj. 

Aquae, q. s. ad f^iij. M. 

S. Two teaspoonfuls once, twice, or three times daily, for a child of two years. 

Or, 

R. Resin. Podophylli, gr. y^. 

Spt. Vini Rect., "nixv. 

Syrupi, q. s. ad fgj. M. 

S. One teaspoonful for a dose.] 

When a few months have passed over, or if the child be 
brought up by hand, better than all medicines by the mouth 
is the plan of attempting to modify the diet, or of exciting 
the lower bowel to expel its contents by enema or supposi- 
tory. A teaspoonful of fine oatmeal may be added to the 
morning meal, or barley-water may be mixed with each 
meal. Friction should also be applied to the abdomen, 
morning and evening, either by the hand alone or combined 
with an oily embrocation. 

The barley-water is given as in previous cases. The oat- 
meal should be given, a teaspoonful well rubbed up with a 
little cold milk till it is of the consistence of cream ; hot 
milk to the required amount for the meal is then to be 
added, and the whole boiled for a few minutes, when it is 
ready for use. [As boiled milk is constipating it is better 
to prepare the oatmeal as follows : Take a teaspoonful of 
finely ground Bethlehem oatmeal, add to two fluid ounces 
of water, and heat without boiling but with stirring for five 



56 THE DISEASES OF CHILDREN. 

minutes, remove from fire, add the same quantity of milk, 
two teaspoonfuls of cream, and half a teaspoonful of sugar of 
milk. This preparation is suited for an infant six weeks old.] 
If it be necessary to add an alkali, a grain or two of bicar- 
bonate of sodium can be used, as being devoid of the con- 
stipating tendency often observed with lime-water. For an 
enema all that is necessary is to take two or three ounces 
of warm water and lather a little yellow or curd soap into 
it, and inject it by means of a caoutchouc bottle syringe. A 
drachm or two of castor-oil may be added to the soap 
and water if necessary. An enema may be administered 
every morning, or even twice a day if necessary, and I 
know no objection to its daily use as long as may be 
requisite. It is never to be given unnecessarily, but if the 
bowels do not act spontaneously the action should be en- 
sured by an enema, and this may be done without any fear 
of inducing such a habit as would require its permanent use. 
It is but seldom that the bowels fail to act properly when 
the diet becomes more varied. 

Should the constipation be associated with much flatulence 
and pain, a teaspoonful of fluid magnesia may be given com- 
bined with a little spirit of nitric ether and sulphate of mag- 
nesium iF. 7). If associated with heartburn, which may be 
known by hiccough, which causes the child to cry or make 
faces, at the same time that it performs certain gustatory 
movements, bicarbonate of sodium is to be given, and it 
may be combined with tincture of nux vomica, as recom- 
mended by Dr. Eustace Smith | F. 8). This combination is 
also useful when the bowels are persistently sluggish, from 
the nux vomica which it contains. A little glycerine may 
be added with advantage. The bicarbonate of sodium is 
also useful when the eructations are sour-smelling from fer- 
mentation going on in the stomach. It may be usefully 
conibined with bismuth and carminatives I F. 9, 10). 



DIET DISEASES: ATROPHY FLATULENCE — COLIC, ETC. 57 

Other remedies may occasionally be found useful. Aloes 
powdered and dissolved in milk is recommended by some; 
five or six grains of Socotrine aloes may be given three or 
four times a day till the bowels act; or it may be made into 
a syrup, a drachm of the aloes to an ounce and a half of 
syrup with some liquid extract of liquorice ; or a small dose 
of euonymin (best administered in a powder with white 
sugar, gr. ^ of the drug) ; or a drop or two of the tincture 
of podophyllin : but they will not be required often if atten- 
tion be paid to the causes of the constipation, if the diet be 
carefully regulated, and the general hygiene of the nursery 
— warmth, bathing, cleanliness — be kept at the right stan- 
dard. 

In children past the age of babyhood constipation is an 
occasional and somewhat troublesome affection, It is more 
common in girls than in boys. The subjects of it are usu- 
ally thin and plaintive, wayward in temper, without anything 
definitely wrong ; their appetites are capricious, the breath 
often offensive, and they are supposed to have worms. 
Children they are who do no credit to good living, and 
who trouble the doctor because they are somewhat tardy in 
answering to his remedies, and because some of the symp- 
toms may lead him to suspect the onset of the formation of 
tubercle. Henoch* mentions even more extreme cases in 
children of seven and nine years in whom the constipation 
gradually leads to extreme distension of the whole abdo- 
men, with pain and tenderness, so as to simulate peritonitis. 

For constipation in older children, regular habits must be 
enforced. It is at least as necessary that a child should go 
to the closet regularly, as that she should do certain house- 
hold duties, or perfect herself in certain accomplishments 
with regularity. But this is a matter that many mothers 

* Loc. cit., p. 449. 



58 THE DISEASES OF CHILDREN. 

never think of. In the next place, cases of this kind are 
not adapted for the exhibition of purgatives. Some gentle 
alkaline laxative may be given for a day or two, and if it 
were not so nauseous to most palates, none is better than 
the old-fashioned rhubarb and soda (F. 11). Hospital out- 
patients take this, and even like it, but other children very 
seldom do, and a dessert-spoonful to a tablespoonful of the 
liq. magnesii carbonatis is taken by them with less repug- 
nance. The sulphate of magnesium maybe rendered fairly 
palatable with raspberry vinegar (F. 12). There is no objec- 
tion to the administration of a single purgative of more 
drastic nature if it be only to insure that the intestinal canal 
is cleared of all irritating contents. A grain of calomel, 
with six or eight grains of compound jalap or scammony 
powder, is efficient for such a purpose for a child of seven 
to ten years old; or a quarter to half a Tamar Indien 
lozenge may be given instead, the remedy being more 
pleasantly administered in the lozenge form. But drugs of 
this kind are to be given with this* one distinct object in 
view, and they must not be resorted to repeatedly. When 
all such preliminary difficulties are cleared away, the con- 
stipation is to be cured by plenty of exercise in the open air; 
by a diet of plain nutritious food, with green vegetables and 
fruit ; by insisting upon the proper mastication of all food, 
and by drugs which act* as hepatic stimulants and tonics ; 
strychnia may be given as a tonic to the bowels and arsenic 
and iron as blood restorers. Euonymin and podophyllin in 
small doses are useful members of the former class. (F. 
13, 14, 15, 16, 17.) 

[The tincture of aloes and myrrh acts well in these 
cases, as a stomachic, laxative, and tonic to the mucous mem- 
brane of the bowels.] 

Constipation, when it is unassociated with other symp- 



DIET DISEASES! ATROPHY FLATULENCE — COLIC, ETC. 59 

toms, is not a condition which does much harm, and it may- 
be remedied by patience and a little management. 

Constipation, when it is associated with sickness, always 
requires careful investigation, and the possibility of intussus- 
ception or of brain disease should be remembered. 

Constipation, when it is obstinate from birth, demands an 
examination of the rectum. Narrowing of the canal from 
the presence of some partial septum or other congenital 
malformation, though rare, is for that reason apt to be over- 
looked in its less extreme phases. And other forms of 
malformation, such as internal stricture of some portion of 
the small intestine, and even hernia, occasionally exist. But 
such cases are very rare. 

Lastly, constipation in young children is by no means 
uncommonly associated with small fissures about the anus. 
The pain of defaecation is so severe in these cases that the 
sphincter contracts tightly and prevents any successful ex- 
pulsive efforts. 

If there be an anal fissure, the bowels must be kept 
slightly relaxed, to obviate any stretching of the part, and 
the fissure should be treated locally by keeping the lower 
inch of the bowel and anus well greased with an ointment 
composed of equal parts of lead, zinc, and mercurial oint- 
ment, or it may be dusted with equal parts of calomel and 
oxide of zinc. Occasionally it may be necessary to paint it 
with nitrate of silver, and once or twice it has been necessary 
to stretch it forcibly with the fingers, on the same principle 
as the surgeon finds it necessary in the adult to divide the 
superficial sphincter with the knife. 



60 THE DISEASES OF CHILDREN. 



CHAPTER IV. 

DIARRHCEA. 

" When the alvine excretions are abnormally liquid, fre- 
quent and profuse, whether they consist of the residue of 
undigested or incompletely digested food ; of the product 
of the secretions of the intestine, the pancreas or the liver ; 
whether they contain blood or not, or the debris of the 
mucous membrane, we say that there is diarrhoea."* Some 
writers have described many forms of diarrhoea, and would 
thus make the subject a complicated one for the student ; 
but there is no corresponding morbid anatomy for the dif- 
ferent kinds of looseness of bowels, and the results of treat- 
ment suggest a very simple division. Diarrhoea is the 
symptom of disordered or excessive function on the part 
of the neuro-muscular apparatus of the intestines, and any 
organ which depends for its action upon organic muscular 
fibre is liable to such functional derangements as may by 
their continuance become confirmed as a habit, and yet have 
no appreciable morbid anatomy. The uterus may persis- 
tently abort time after time from the irritation of a syphilitic 
foetus, for example, and show in itself no reason for so 
doing. The stomach may repeatedly cast its contents in 
similar fashion, and in children, and less frequently in adults 
also, diarrhoea may continue for months, resisting all treat- 
ment without adequate cause in any structural lesion. The 
student must not therefore conclude, as he is often inclined 
to do, that the diarrhoea being chronic and intractable, it is 

* Trousseau, " Clinique Medicale," 1868, vol. iii., p. 98. 



DIARRHCEA. 6l 

due to ulceration of the bowel ; much less that not only is 
there ulceration, but that that ulceration is tubercular. 

The arrangement I propose to adopt as simple, and 
according with practice, is into acute and chronic diarrhoea, 
and in limine this generalization may be made : 

Looseness of bowels which has existed any length of 
time should be closely investigated, as it is pretty sure to 
prove troublesome to stop, and may indicate serious disease 
of the intestine and mesenteric glands; Avhile the diarrhoea, 
which comes on suddenly, is associated with vomiting, and 
prevails to such an extent in the hot season of the year that 
it has received the name of summer diarrhoea, though by no 
means wanting in its more special dangers, need give rise to 
no such anxieties, being usually readily curable by simple 
means. 

Acute Diarrhoea. — Of late years summer diarrhoea has 
been thought to be an index of the sanitary condition of 
large towns, and to be due in larger measure to filth and 
putrefactive processes than, as had been previously thought, 
to simple atmospheric disturbances, the nervous activities of 
dentition, and so on ; and this view is probably correct. 
The very existence of large towns implies the presence of 
more or less material which possesses the power of origi- 
nating putrefaction of all sorts. Aggregation is necessarily 
more favorable to the transmission of septic material than 
isolation can be. The subjects of this complaint are all 
under five and most of them under two years of age, that is 
to say, they are in great measure milk-feeders, and milk is 
a fluid which is very sensitive to contamination.* It may 

* I may remind the reader that all organic liquids, though under ordinary- 
circumstances liable to decomposition, remain absolutely unchanged as long 
as they are protected from particulate contagion, and there is good evidence 
that the various kinds of fermentation and putrefaction are due to the intro- 
duction and growth of various kinds of bacteria. Of milk in particular I 






62 THE DISEASES OF CHILDREN. 

therefore be very readily supposed that whatever tends to 
lessen the risk of this — and what more so than paying 
attention to the sanitary condition of a town ? — will by 
lessening the risk of decomposition to which milk is liable, 
by so much lessen the amount of summer diarrhoea. 

But the whole subject is not wholly embraced by this 
statement. There are some children, and some adults too, 
who are readily affected by alterations of barometric pres- 
sure, electrical atmospheric disturbances, and so on. Loose- 
ness of bowels is noticed in such subjects on any sudden 
fall or rise of the mercurial column, any sudden change 
from one extreme to the other of heat or cold, or in thun- 
dery weather. 

What such reactions may indicate etiologically ; how far, 
that is to say, such conditions indicate changes in the food, 
and how far act immediately upon the system, it is impos- 
sible to say, and happily for the purposes of therapeutics, 
though the facts are worthy of recognition, the treatment is 
unaffected. Diarrhoea is supposed, and probably correctly 
1 so, to own many other causes, such as chills, over-feeding, 
improper feeding, dentition, pyrexia of all sorts, rickets, 
syphilis ; and some of the reputed causes are associated 
with certain signs which, as I have said, have justified to 
some the description of many varieties. It is, however, 
sufficient to say that in some cases of diarrhoea there is 
more or less fever, in others perhaps vomiting ; in others 

may quote from Sir Joseph Lister, whose researches in this domain are well 
known (*■ On Lactic Fermentation,*' Trans. Path. Soc. of Lend., vol. xxix., p. 
45; : "I once met with a bacterium, but only once, that would not live in 
milk ; for extremely numerous as the varieties of bacteria appear to be, almost 
all of them seem to thrive in that liquid." The outbreaks of such diseases as 
typhoid fever, scarlatina, diphtheria, and even of epidemic diarrhoea, which 
have of late years been traced to a milk source, must, according to present 
knowledge, be explained in this way, although the actual bacterium of germ 
has not as yet been demonstrated. 



DIARRHCEA. 



63 



there are lumpy motions of undigested food : a want of bile ; 
an excess of bile ; a rice-watery discharge. In other cases 
the evacuations are of peculiar color, pink or green. Some 
are peculiarly offensive. 

In one form or another during the summer months the 
out-patient room of any children's hospital is overrun with 
cases of diarrhoea, mostly infants of four or five months old 
and upwards. The complaint varies much in severity. To 
take a common case : the child has perhaps been vomiting 
and purged for some days with little apparent disturbance of 
its health. There is a certain amount of pallor, a little fret- 
fulness and restlessness, and slight rise of temperature. It 
is usually thirsty, will drink any quantity of cold water, and 
milk is vomited undigested in curds. The mouth is some- 
what dry; the tongue redder than natural, and its papillae 
are prominent. There may be some erythema about the 
buttocks, and the motions are usually liquid, green, and 
offensive. Sometimes the evacuations are bright yellow; 
in others again pale. Suddenly perhaps, the temperature 
runs up to ioi° to 103 , and the evacuations speedily be- 
come colorless, profuse, and watery, with an odor which is 
rather sickening than foully offensive, or pinkish in color 
like meat juice. The profuse watery evacuations are liable 
to be accompanied by extreme collapse, the temperature 
falling in proportion, and death may result within a few 
hours. Sometimes a healthy infant is suddenly seized with 
profuse purging and vomiting, it becomes of a leaden pallor 
with cold surface, moist skin, depressed fontaneile and 
sunken eye, so closely resembling a case of Asiatic cholera 
that such attacks have received the name of Cholera Infan- 
tum. 

The evacuations in these cases have been subjected to 
microscopical examination, but only to find them containing 



64 THE DISEASES OF CHILDREN. 

epithelium and vibriones such as may be found in most 
cases of diarrhoea. 

I shall say no more as regards varieties ; acute diarrhoea 
may be of all grades of severity. Any more minute de- 
scription would but tend to confuse and throw the student 
off his guard, perhaps upon the first occasion on which 
he fell upon his own resources ; but this much may be 
insisted upon, that in order that he may have some reliable 
notion of the severity of the case it is essential that the 
doctor should see for himself what is passed by the bowels. 
The late Mr. Hilton was in the habit of saying to his 
dressers — " Never lose an opportunity of examining a rec- 
tum." With equal force it may be said to the student of 
diseases of children, " Never miss an opportunity of exam- 
ining the alvine evacuations." The appearances of the 
excreta will often give a valuable suggestion for treatment, 
while they will often puzzle us if we have not made our- 
selves familiar with them. 

Morbid Anatomy. — Nothing definite can be described. 
In many cases there is no morbid appearance of any sort ; 
in others there is some slight swelling of the solitary glands 
and Peyer's patches ; rarely some ulceration of the follicles 
and glands; a streaky ecchymosis here and there; or an 
unnatural pallor of the mucous membrane, with an excess 
of mucus along the canal. But these are all such appear- 
ances as may be equally present without diarrhoea, and 
cannot therefore be taken as certainly indicative of the dis- 
ease the child has succumbed to. On the other hand, more 
pronounced lesions are sometimes found, more especially in 
those cases that are associated with fever. The symptoms 
may not have been very definite during life, and yet after 
death the mucous and submucous coats of the bowel are 
swollen, ecchymosed, covered with an adherent layer of 



DIARRHCEA. 65 

false membrane, and infiltrated with yellow gelatinous 
lymph or semipurulent fluid. 

Diagnosis. — But few mistakes are possible. An acute 
enteritis may possibly be overlooked and the case considered 
one of simple diarrhoea. This is most likely to be avoided 
by paying attention to the temperature, which is more likely- 
to be high in enteritis, and to the tongue, which is more 
red and furred also. Much fulness of the abdomen and 
abdominal tenderness might also in certain cases put one 
on his guard. But no dogmatic statement can be made. 
It is conceivable also that intussusception might mislead at 
its onset. There is sudden vomiting, and rather profuse 
purging may accompany it till the lower part of the large 
intestine is cleared out and blood comes. But in acute 
intussusception faecal evacuations should soon cease and 
blood and mucus alone be found. This, the persistence 
of vomiting, the probable existence of the sausage-like 
tumor in the abdomen, and the presence of a palpable 
polypoid mass in the rectum, should* in most cases be quite 
sufficient to prevent mistakes. 

Prognosis. — This must depend upon the amount of col- 
lapse. Severe collapse is always most dangerous. The 
presence of continued fever, with a red dry tongue, is also 
an unfavorable sign. 

Treatment. — In uncomplicated cases of no more than 
average severity, and where there is an absence of collapse, 
a laxative, such as castor-oil or fluid magnesia, should be 
given, and the diet restricted to easily digestible fluids. 
Formula 3, 5, or 7 will in most cases be successful, and 
milk and lime-water or milk made alkaline with a grain or 
two of bicarbonate of sodium, or thin broth, will form a 
suitable food for twenty-four or thirty-six hours. When 
the purging is profuse and very liquid, associated with 
vomiting and much collapse — the symptoms which speci- 



65 THE DISEASES OF CHILDREN. 

ally indicate infantile cholera — a warm bath and sometimes 
a mustard bath should be given at once; if the latter, about 
a tablespoonful of mustard to the gallon of water is used, 
and the child is kept in it till the nurse's arms tingle. It 'is 
then to be wrapped in blankets and kept very warm in the 
•nurse's arms or by hot bottles. Sometimes the choleraic 
symptoms are associated with very high temperature, 105 ° 
to 108 , in which case the tepid bath is to be employed fre- 
quently. The child may be put into a bath of 85 ° to 90 , 
and the temperature of the water lowered to 8o°, and may 
be kept in it five or ten minutes, then wrapped in a blanket, 
and the process may be repeated every three or four hours 
if necessary. The cold bath was recommended by Trous- 
seau as a means of subduing nervous symptoms, and lately 
its employment has again been advocated in these bad cases 
of summer diarrhoea associated with high fever. The in- 
ternal treatment will depend upon the existence or not of 
urgent vomiting. If this is not very severe, small doses of 
castor-oil may still be given. They will speed onward any 
noxious matters in the intestine without increasing the 
state of collapse. If the vomiting is incessant, half-grain 
dose of hydrargyrum c. creta or one-sixth grain doses of 
calomel should be given every hour for three or four doses. 
Henoch speaks highly of hydrochloric acid in small doses 
and also of creasote (F. 18). Brandy must be given in 
doses of twenty to thirty drops every two, three, or four 
hours, as may be necessary. Ether may be substituted in 
drop doses in syrup, and for hospital patients I usually 
order rectified spirit. It can be given either with the medi- 
cine or mixed with an aromatic water separately. In the 
worst cases a speedy temporary rally maybe obtained and 
time gained by a subcutaneous injection of ten drops of 
brandy diluted with water. Food is to be administered in 
the smallest quantities, and of all others whey, if it can be 



DIARRHOEA. 



6 7 



procured quickly enough, is the best. Barley water, the 
eau albumineuse of Trousseau,* or thin veal or chicken 
broth, are all useful in their turn. The point in giving 
directions for the feeding is to beware of doing too much 
and so bringing about a recurrence of the vomiting. A 
teaspoonful is a small quantity, but a teaspoonful retained 
is better than a tablespoonful vomited. 

One exception may be made to the inclusion of all forms 
of acute diarrhoea under one head. Diarrhoea is occasion- 
ally associated with considerable fever, quick pulse, and a 
thickly furred tongue. Under these circumstances the 
abdomen is usually full and rather tender, the motions are 
liquid, or partly liquid and partly lumpy, faecal or green in 
character, but mixed with an excess of mucus. Such cases 
occur at all periods of the year, sometimes during dentition, 
sometimes after some improper food ; in symptoms they 
correspond tx> what has been described as acute dyspepsia, 
infective gastritis, or muco-enteritis, and they should be 
treated -by a preliminary dose of castor-oil ; followed by a 
simple alkaline mixture, or by demulcents, such as almond 
oil, sweetened with glycerine, and made into an emulsion 
with gum tragacanth (F. 20). A few drops of ipecacuanha 
wine may be added to either mixture with advantage. In 
some cases a minute dose of Dover's powder with bismuth 
relieves the pain in the abdomen, and procures sleep. In 
the more severe cases, with pronounced intestinal inflamma- 
tion, the chief aim must ever be to sustain the child by 
suitable nourishment, and if need be by stimulants, so as 
to allow the disease to run its course and reparative action 
to take place. 

[There are two forms of summer diarrhoea of such 
prominence in American cities that they demand a more 

* The white of two eggs is diluted with a pint of water and sweetened and 
flavored by some aromatic. 



68 THE DISEASES OF CHILDREN. 

detailed description. These are entero-colitis and cholera 
infantum. 

Entero-colitis. — This is by far the more common of the 
two, and chiefly affects children in their " second summer," 
and those belonging to the poor, who are doomed to pass 
the hot months in crowded, ill-ventilated and filthy locali- 
ties of large cities. 

Anatomical Lesions. — There is hyperaemia of the intesti- 
nal mucous membrane, commonly limited to the ileum and 
colon and most marked about the ileo-caecal valve and in 
the sigmoid flexure. The isolated glands are enlarged, 
appearing like grains of white sand scattered over the 
mucous surface, and the Peyer's patches are tumid, pro- 
jecting and punctated. The peritoneum over the inflamed 
glands shows areas' of arborescent injection, and the mesen- 
teric glands are moderately enlarged. The stomach is 
either normal, or the seat of catarrh, the mucous membrane 
being thickened, softened and reddened. 

Should the disease assume a chronic form — the "-chronic 
diarrhoea " of our author — the glands break down and super- 
ficial rounded ulcers are formed ; there may be, also, linear 
ulceration of the mucous membrane at the points of deepest 
congestion. 

Etiology. — The main causal factors are : a. Residence in 
large cities ; especially in those quarters where, the streets 
being narrow and ill-kept, and the houses overfilled and 
dirty, there are accumulations of organic matter to be 
decomposed and contaminate the atmosphere with noxious 
gases and bacteria, b. High temperature, particularly when 
associated with a moist air. The disease, almost absent in 
winter, begins to be noticed about the middle of May, gradu- 
ally increases to rage in epidemic profusion in July and 
August, and disappears with the cool weather of the latter 
part of September, c. Improper food. Babies hand-fed 



DIARRHCEA. 



6 9 



from birth and those who are weaned early suffer most. 
Impure and sour milk, farinaceous preparations in excess, 
" tastes " of table food and fruit are most potent in producing 
an attack, d. Age. The majority of cases occur between 
the ages of six and eighteen months, one-fourth as many 
from eighteen to twenty-four months, and a smaller propor- 
tion between birth and the sixth month. After the second 
year attacks are much less common. 

Symptoms. — The actual attack is preceded by restlessness, 
disturbed sleep, partial anorexia, sour-smelling eructations, 
slight increase in the number and decrease in the consist- 
ency of the faecal evacuations, and heat of the palms of the 
hands and soles of the feet. 

In one or two days, vomiting and diarrhoea begin. The 
former is more or less obstinate, and the ejecta consist of 
sour, badly digested food. The stools range from six to 
twenty or more in twenty-four hours, and vary greatly in 
character from time to time. They may be semi-solid, 
yellow, with a faecal odor ; " or liquid, green and acid; or 
contain mucus or blood; or, finally, be almost serous and 
very offensive. The act of defecation is preceded by pain, 
and there may be tenesmus and slight rectal prolapse ; in 
the latter condition blood is most apt to appear in the 
stools. 

The tongue is dry, red at the tip and edges, with a light 
white coating in the centre, appetite is diminished, thirst 
increased, and the abdomen is distended and sometimes 
tender to pressure. The surface is hot and dry, the ther- 
mometer indicating a moderate pyrexia continuous for the 
first three or four days, but afterward remittent. The pulse 
is feeble and runs up to 120 or even 140 per minute. The 
urine is scanty, high-colored and muddy, and passed at long 
intervals. 

Early in the course of the disease — after a single day if 



JO THE DISEASES OF CHILDREN. 

the diarrhoea be severe — the face becomes pale, the eyes are 
sunken, lustreless and surrounded by dark rings, the nasal 
lines of Judelot appear, the fontanelle, if membranous, is 
depressed, the body wastes, the muscles grow flabby, the 
skin of the buttocks and inner surfaces of the thighs is 
reddened by the acid stools and concentrated urine, and 
there is excessive prostration. 

When death approaches the patient either becomes 
drowsy, apathetic and cold, or fretful, with incessant vomit- 
ing, dry burning skin, rolling of the head from side to side, 
and perhaps unilateral or partial convulsions. 

If there be a tendency to recovery, the vomiting stops, 
there is more appetite, the skin grows moister and cooler, 
the urinary excretion is re-established and the langour and 
apathy diminish. 

Diagnosis. — There is little difficulty in distinguishing 
entero-colitis. The fever, the vomiting, the number and 
appearance of the stools, the age, season and locality of 
occurrence, and the almost epidemic prevalence of the dis- 
ease are characteristic. 

Prognosis . — While a large proportion of cases recover 
under proper treatment, the outlook is always grave, and 
particularly so in the children of the poor, with whom it is 
impossible to practice the most efficient means of cure, 
namely, removal to the fresh-air of the country or sea- 
shore. Relapses are apt to occur, and the disease is liable 
to become chronic when it is very difficult to manage. An 
attack may prove fatal in four or five days ; it may however 
be protracted for two weeks, the last is the usual duration 
of severe cases ending favorably. 

Treatment — People who have not the means to take their 
families to a place of safety in the country or at the sea- 
shore for the summer months, may yet do much in the way 
of prevention by keeping their children, during the day, in 



DIARRHOEA. J I 

the fresh air of public squares and parks, by bathing, by- 
proper and clean clothing, good food, and attention to the 
cleanliness of beds and sleeping rooms. Clean streets are 
apparently too much to expect in the present state of our 
municipal governments, but there is no question that any 
improvement in this respect would lessen the frequency 
and mortality of summer diarrhoea. 

When an attack occurs the patient must, if possible, be 
sent at once from the city, the resort selected being near at 
hand, lest the journey be too fatiguing, but such as to afford 
a decided change of air. The effect of such a change is 
rapid and almost magical ; it is necessary, though, to make 
a long stay, since if the child be brought back to town in 
hot weather, a relapse is almost certain to occur. If the 
parents be too poor to afford this, they must keep their 
child out of doors in the cool of the morning and evening, 
or spend the day with it in a public park, or still better 
take it for a short excursion in a river steamboat. The 
heat of the day should be passed in as cool a spot as can 
be obtained. It is well to let the child rest on a cool clean 
bed, and to forbid its being constantly nursed on a hot lap 
or shoulder.- 

The clothing must be as thin as possible provided always 
that woollen is worn next the skin. Several times a day in 
the early stages of the attack, the whole surface of the body 
ought to be sponged with water at 8o° F. and carefully 
dried with gentle friction ; after prostration has set in, full 
warm baths are to be employed. 

In ordering the diet, quantity as well as quality must be 
definitely stated, for the increased. thirst causes much more 
liquid food to be taken than can be digested. It is better 
to meet this demand by bits of cracked ice and moderate 
quantities of iced filtered water, and to proportion the 
amount of food to the enfeebled digestive powers. 



72 THE DISEASES OF CHILDREN. 

This may be readily done with nursing babies by restrict- 
ing the intervals of feeding to two or three hours, according 
to the age, and by reducing somewhat the duration of each 
sucking. 

With hand-fed children it is still easier to fix the quantity ; 
as to quality, good sound cow's milk must form the basis of 
every food. The following is a good preparation for a child 
of twelve months : 

Milk, ...... six tablespoonfuls. 

Cream, ...... one tablespoonful. 

lime-water, ..... five tablespoonfuls. 

Sugar of milk, ..... one teaspoonful. 

Mix in a clean tin cup, pour into a clean bottle, adjust tip, and warm by 
plunging into hot water. 

Should it be impossible for the child to retain this quan- 
tity, one-half, or even one-fourth of it only may be given. 

It is always worth the trouble to see that the infant's milk 
is received and kept in a perfectly clean and special vessel ; 
that the bottles and tips (no tubular arrangement should 
ever be used) are also perfectly clean, and that each meal is 
prepared separately at the time of serving. In very hot 
weather, and when ice is scarce, it is a good plan to boil the 
whole day's supply of milk, when it comes in the morning, 
to keep it from souring, but under no circumstances should 
the meals for the day be mixed en masse. 

When the milk preparations are vomited, or passed un- 
digested in the stools, whey mixtures, strippings, or meat- 
juice have to be resorted to. 

The medical treatment, should the case be seen early, may 
be begun by a laxative, as one teaspoonful of castor oil with 
five drops of paregoric* Afterwards, while the stools are 

* All the prescriptions given in this section are proportioned for children 
one year old. 



DIARRHCEA. 



73 



yellow, homogeneous, and have a faecal odor, alkalies and 
astringents are demanded ; as : 

R. Sodii Bicarbonatis, ...... gr. xxxvj. 

Syr. Rhei Aromat., f,? ss - 

Aq..Menthae Pip., .... q. s. ad f giij. M. 

S. — One teaspoonful every two or three hours. 

When the stools are green, acid, and numerous, alkalies 
with opium do best : 

R. Tr. Opii Deod., mvj. 

Bismuth. Subcarb., . ..... gr. lxxij. 

Syrupi, ........ f^ss. 

Misturae Cretae, .... q. s. adfgiij. M. 

S. — One teaspoonful every two or three hours. 

Good results, too, are sometimes obtained in tedious cases 
by minute doses of calomel with opium and chalk. It is not 
advisable to continue these longer than one or two days. 

Very frequent and serous stools require more powerful 
astringents, as nitrate of silver internally and by enema, or 
sulphuric acid. For the latter, the following is a good for- 
mula: 

R. Acid. Sulph. Aromat., TUxxiv. 

Liq. Morphise Sulph., f^j. 

Elix. Curacoae, ...... f^ij. 

Aquae, q. s. adfgiij. M. 

S. — One teaspoonful every three hours. 

Counter-irritation by mustard plasters to the belly is use- 
ful. Stimulants are required when prostration sets in, and 
must be given in doses and at intervals adapted to the de- 
mands of the case. 

Applications of oxide of zinc ointment, with cleanliness, 
cure the intertrigo of the buttocks and thighs most quickly, 
or, at least, keep it in check until the cause is removed. 



74 THE DISEASES OF CHILDREN. 

Attention to diet and hygiene is not to be relaxed when 
convalescence is established, and after the measures calcu- 
lated to check diarrhoea are unnecessary, digestants, as wine 
of pepsin, and tonics, as the ferrated elixir of cinchona, are 
still required to restore the health. 

Cholera Infantum is the analogue of cholera morbus in 
the adult. 

Anatomical Lesions. — In typical cases, the gastro-intestinal 
mucous membrane is congested, thickened, and softened, 
and the glands, both solitary and agminated, are enlarged. 
When the patient survives the choleraic stage, and dies sub- 
sequently of a more protracted diarrhoea, there is more in- 
tense inflammation, with ulceration of the intestinal mucous 
surface. In addition, the sympathetic nervous system is so 
involved as to allow the transudation of serum from the 
bloodvessels into the intestines, and lead to alterations in 
the functions of the heart, lungs, and kidneys. 

Etiology. — Infants from six to twelve months are the most 
ready subjects, but it may occur at any age up to two years. 
In other respects, the causation is identical with that of en- 
tero-colitis. 

Symptoms. — The onset of cholera infantum is sudden, 
whether it occurs in the midst of health or during the course 
of an ordinary diarrhoea. The first symptom is the expul- 
sion of very large watery stools ; these may be so serous as 
to soak away into the napkins without leaving any more 
stain than healthy urine, or they may contain yellow or 
green flocculi and little masses of mucus ; or, again, they may 
be composed of dirty-brown liquid. In the first two in- 
stances they are odorless, in the last they have a peculiar 
musty, putrid smell, which clings to the body and clothing 
of the patient. The number of evacuations varies from ten 
to thirty in twenty-four hours. 

Soon the stomach becomes intensely irritable; everything 



DIARRHCEA. 



75 



is vomited almost as soon as swallowed, and there is severe 
retching. The appetite is lost, there is intense thirst, the tongue 
is dry, pasty, and protruding, and the abdomen is flaccid. 
There is great restlessness ; the temperature runs up to 105 
or even 108 , the pulse is small, and counts from 130 to 150- 
per minute, the breathing is irregular, and the urine almost 
suppressed. After a few hours the infant seems to have 
melted into a mere shadow of himself; his face is pale and 
pinched, his eyes and cheeks sunken, and the lids and lips 
parted from muscular relaxation. The fat of the body melts 
away, the muscles grow soft, and the skin, dry and cadav- 
erous in color, hangs in loose inelastic folds. Next, there 
is rapid collapse, with cold extremities and breath ; thready, 
uncountable pulse, unequal respiration, drowsiness, apathy, 
and totally suppressed urine. 

As death draws near, the vomiting stops, the skin is 
clammy, the face set, and the patient sinks into a condition 
of semi-coma. The end comes quietly, or is preceded by 
slight convulsive movements. 

The attack may prove fatal in from one to four days, or 
the type may change, and death occur later from secondary 
entero-colitis ; sometimes recovery takes place. 

Diagnosis. — The character of the stools, the extreme irri- 
tability of the stomach, intense thirst, high temperature, 
disturbed respiratory rhythm, and rapid emaciation and 
collapse, are distinctive features. There is a certain re- 
semblance between this disease and sunstroke, but the 
two conditions have little in common beyond the fact that 
they both occur in hot weather. 

The prognosis is very unfavorable. Early removal to the 
country or sea-side offers the best chance for recovery. 
Otherwise daily airings and steamboat excursions must be 
resorted to. 

Treatment. — To replace the great waste, food and water 



j6 THE DISEASES OF CHILDREN. 

must be given in such quantities as can be retained — even 
a teaspoonful at a time — and at intervals corresponding in 
frequency with the smallness of the amount. The quality 
of the food must be the same as in entero-colitis. 

To check the purging, astringents and opium are necessary, 
the sulphuric acid mixture, given on p. 73, is very efficient. 
At the same time, an enema containing two or three drops 
of tincture of opium should be administered every three 
hours. Mustard draughts should be applied to the abdomen 
three times a day, or a flax-seed poultice warmed with a dash 
of mustard may be worn constantly, and the body must be 
sponged several times daily with water at a temperature 
of 95 . 

The patient should lie upon a bed, not in the lap ; perfect 
cleanliness of person, diapers and clothing is essential, 
and the sick-room must be as large, cool and airy as can be 
commanded. 

Stimulants are necessary from the first. Five or ten drops 
of whiskey in a teaspoonful of lime-water may be given 
every two hours in the beginning, and increased as circum- 
stances demand. Carbonate of ammonium may be combined, 
if the stomach permits, in bad cases. 

In collapse, the temperature must be kept up by hot flan- 
nel wraps, and hot-water bottles, and quiet in a horizontal 
position maintained. In this stage opium is to be used 
with caution, on account of its tendency to increase the 
stupor. 

In the fortunate favorable cases, secondary diarrhoea is to 
be treated carefully, and the general strength built up by 
good, digestible food, tonics and fresh air.] 

Chronic Diarrhoea is very generally insidious in its origin. 
It often happens that not till months after its commencement, 
and not till emaciation has made some progress, is the child 
brought for treatment. In reply to questions, we are told 



DIARRHOEA. 7J 

that the bowels have always been loose — perhaps what 
began as an acute diarrhoea has become perpetual. Some- 
times the attack has been the outcome of one of the exan- 
themata ; but however this may be, the child is brought 
because " as soon as any food is taken it goes through him, ,, 
and for some imaginary enlargement of stomach, these be- 
ing indications to the mother of " consumption of the 
bowels." It is but seldom, however, that this popular 
diagnosis is correct ; and in at least nine cases out of every 
ten, consumption of the bowels means no more than the 
disorder attendant upon improper feeding. 
, Causes. — Chronic diarrhoea occurs for the most part in the 
ill-kept children of the poor of large towns ; in infants whose 
mothers are out at work all day long, and who are conse- 
quently fed on anything on a week-day, and probably, as a 
treat on Sundays, on a little of everything that the parents 
eat; in the ill-washed, with a skin choked with perspiration, 
dirt, and urine ; in the ill-clothed, with a surface repeatedly 
exposed and chilled , — in all, in fact, who breathe bad air 
and are fed on bad food, and live under conditions hygieni- 
cally faulty. [Entero-colitis is also the cause of a certain 
proportion of cases of chronic diarrhoea occurring in children 
from six to eighteen months old.] In the children of the 
well-to-do, it usually results from improper feeding — not 
necessarily from food intrinsically bad, but rather from food 
which is not adapted to the particular case. In many of 
the children in this class of society, the greatest care and 
forethought has been exercised; still, there is something 
wrong in the food or in its method of administration. 
Chronic diarrhoea is also specially frequent in rickety and 
•syphilitic children, and is also liable to begin in any who 
may be recovering from measles, whooping-cough or other 
debilitating disease. 

Symptoms. — The early history of cases of chronic diar- 

7 



78 THE DISEASES OF CHILDREN. 

rhoea can but seldom be obtained from that class of society 
which furnishes the most abundant examples; but from 
such children as have been under careful observation, it 
would appear that an acute attack of diarrhoea, acute dis- 
ease of one kind or another, or exposure to cold, are its 
usual precursors. There are many children, moreover, who 
are voracious from birth, who take their food with great 
rapidity, take more than is requisite, and who show symp- 
toms of indigestion and suffer pain afterwards. Any of these 
conditions will lead to diarrhoea. The motions are at first 
abundant without being very abnormal. Very gradually 
they lose their color and consistency, the child losing its 
plumpness, and dwindling. The motions may at first be 
pultaceous and abundant, lumpy, with a quantity of mucus, 
or grumous and more like pus ; but in the late stages they 
become more and more frequent, amounting sometimes to 
twenty or thirty in the twenty-four hours; more liquid; 
more offensive ; and the color changes to reddish or to a 
dirty-brown water containing green particles — " like chopped 
spinach," an apt comparison — which are considered to be 
altered blood. The child meanwhile slowly wastes. For a 
long time, by a negative rather than a positive process, the 
infant grows older but not larger. For long it is supposed 
to be rather bad-tempered than ill, for in the interval of the 
abdominal pains it may be bright and cheerful ; but by-and- 
by the emaciation cannot be overlooked — it becomes con- 
tinuous, till in extreme cases only a living skeleton remains. 
The skin is brown and dry, hanging in folds upon the body 
and wrinkling the brow ; the buttocks become covered with 
an eczematous rash; the face is pinched and monkey-like; 
the cry, a hardly audible whine; the tongue red and dry, 
rasp-like from the prominences of the papillae, and covered 
with thrush; and the abdomen, moderately distended by 
flatus, shows the intestinal, coils visible through the thinned 



DIARRHOEA. 79 

parietes, and the peristaltic action clearly discernible. Visible 
peristalsis has not the same signification in children that so 
often attaches to it in adults. It may mean the excessive 
activity of the muscular coat of the bowel, but not that the 
muscular coat is hypertrophied ; it may be seen in many an 
emaciated child without any intestinal obstruction being 
present. If the diarrhoea be not arrested by treatment, the 
child gradully becomes more feeble, and sinks into a semi- 
comatose state. The temperature falls below normal; the 
feet and hands are cold and cedematous ; and it either suc- 
cumbs to gradual exhaustion, or else some complication 
occurs — perhaps convulsions, perhaps broncho-pneumonia 
or pleurisy. The* child is, however, often in so feeble a 
condition before the final event that such things create few 
if any fresh symptoms, and they are liable to pass unrecog- 
nized, until a post-mortem examination reveals them. Be- 
sides these, there is a liability to eczema, impetigo and 
ecthyma ; and even gangrene of parts of the surface has been 
recorded. Such is the history of chronic diarrhoea in infants 
— an affection that may last from three or four weeks to as 
many months, or even longer. In older children — that is 
to say, from two years upwards — it is found under three 
conditions of somewhat different import: 1st. As a state 
of irregularity of bowels rather than diarrhoea, the motions 
being often loose, but not unfrequently confined and lumpy. 
The diarrhoea stool is bulky, loosely pultaceous, dark brown 
in color, and offensive. This is due to want of regularity in 
diet, and in certain cases where undigested food appears in 
the evacuations, has received the name of lienteric diarrhoea. 
This form is often associated with thread- worms. It is 
associated also with a certain flabbiness of muscle and fat, 
but hardly ever with any serious wasting. 2d. There may 
be much wasting and abdominal discomfort, the abdomen 
being a little full and the motions muddy and offensive ; in 



SO THE DISEASES OF CHILDREN. 

which case it is due to ulceration of the intestines and tabes 
mesenterica. [Tubercular ulceration, a lesion which fre- 
quently precedes inflammation and caseation of the mesen- 
teric glands or tabes mesenterica, occurs mostly in children 
over three or four years of age, especially when these are 
subjects of the tuberculous or scrofulous diathesis. The 
seat of the disease is the ileum, the parts affected Peyer's 
patches and the solitary follicles. The ulcers are circular or 
oval with uneven ragged edges in which careful examination 
reveals the presence of miliary nodules. They are more 
numerous in the neighborhood of the ileo-caecal valve, over 
which region there is tenderness on pressure, with a certain 
amount of tension of the parietes. The stools are composed 
of dirty-brown fluid with a deposit of flaky matter, small 
black clots of blood, pus and mucus, and are exceedingly 
offensive. The temperature is usually elevated in the even- 
ing, and should the ulceration be marked the mesenteric 
glands are apt to be enlarged.] 3d. There may be little 
wasting, but more pain — the griping coming on almost as 
soon as any food is taken into the stomach, and the evacua- 
tions consisting of undigested food and mucus — -a condition 
which appears to be primarily associated with some disorder 
of innervation {Diarrhee nervcase of Trousseau), although 
excited immediately by the contact of food with the gastro- 
intestinal mucous membrane. [This variety, the true Lien- 
teric diarrhoea y is met with in children from three to nine years 
of age, and is due to an unnatural briskness of the peris- 
taltic action, on account of which whatever food is taken 
is at once hurried through the alimentary canal, with a 
rapidity that allows of but slight digestive change. The 
stools contain little faecal matter, and are composed of almost 
unaltered food so mixed with mucus as to present a slimy 
appearance. They number three or four a day ; the first 
occurs in the morning after rising, the others immedi- 



DIARRHCEA. 



81 



ately after or even during a meal. Each motion is preceded 
by griping pain, and the call is most urgent, so much so 
that the child with difficulty waits for the chamber or 
reaches the closet. The tongue is red at the tip and edges, 
lightly coated or clean over the dorsum. There are fre- 
quent griping abdominal pains with unproductive desires 
to defecate. Wasting and other evidences of failing health 
may or may not be present, and special inquiry is often 
necessary to discover the abnormal condition of the bowels, 
which by many parents are merely considered to be " nicely 
opened."] Prolapse of the rectum is liable to occur in any 
case of chronic diarrhoea, but it is more common in children 
of two to six years than in infants. 

Morbid Anatomy. — The coats of the stomach and intes- 
tines are pale and thin, having suffered from the general 
atrophy, while the mucous membrane of the lower part of 
the small intestine and of the colon is covered with black 
points, giving a cut-beard appearance which is due to altered 
blood pigment deposited round minute ulcerations of the 
solitary glands and follicles. There may in addition be 
more or less superficial erosion of the mucous membrane, a 
streaky appearance from irregular turgescence of the capil- 
lary plexuses, with swelling of parts of the Peyer's patches ; 
and lastly some cases prove to be overlooked examples of 
tabes mesenterica, with their thick-edged ulcers infiltrated 
w T ith yellow material, and perhaps with distinct tubercles on 
the peritoneal aspect. It sometimes happens that a chronic 
catarrh may end in a more acute process. Thus it is that 
occasionally the unsuspected presence of acute enteritis is 
revealed after death. Bronchitis, broncho-pneumonia, or 
atelectasis are the more common affections found in con- 
junction with the intestinal lesions. The more or less 
comatose condition which so often comes on before death 
has been occasionally found to be due to thrombosis of the 



82 THE DISEASES OF CHILDREN. 

cerebral sinuses ; but this is a rare occurrence, and the 
symptoms are probably more often due to the slowing of 
the circulation and the feeble nutrition which ensues, or, 
possibly, as Parrot has suggested, to toxaemia (" Clinique 
des Nouveaux-nes ''). 

Diagnosis. — It is desirable if possible to come to a con- 
clusion whether the diarrhoea is due to tubercular ulceration 
or not. The existence of small follicular ulcers cannot be 
diagnosed with any certainty, but the larger tubercular or 
scrofulous ulcers may be suspected in any child over two 
years in whom the diarrhoea is obstinate and there is much 
wasting. Of late years it has been the custom to teach that 
tubercle is a much commoner disease in infants than had 
been thought; and so, no doubt, it is; none the less it re- 
mains true that of all the cases of chronic diarrhoea met 
with in children, but few are tubercular under eighteen 
months. After two years the question of tubercle must be 
carefully considered. Much pain after taking food, associ- 
ated with a persistently brown watery offensive motion, is 
in favor of ulceration, and so also, with other symptoms, is 
any unusual excess of borborygmi in the intestine. Tuber- 
cular ulceration of the intestine has so much tendency to 
mat together the coils of intestine, and thus hamper their 
action, that some functional disturbances of this kind may 
certainly be expected. These points, and a careful observa- 
tion of the temperature, will generally suffice. A polypus 
in the rectum leads to a discharge of blood and mucus, 
which is sometimes characterized as diarrhoea by the 
mother. An examination of the rectum settles the diag- 
nosis. 

Prognosis. — This must depend upon the result of treat- 
ment. If the diarrhoea lessens and the motions become 
more consistent, then a favorable termination may be hoped 
for. The older the child the better the chances. Much 



DIARRHOEA. 



83 



dryness of the tongue, with redness and enlargement of 
the papillae, accompanied by thrush ; and any oedema of the 
feet and ankles ; are of the worst augury. 

Treatment. — To take the case of older children first, and 
excluding the possibility of tabes mesenterica, the diarrhoea 
which is due to irregularity of diet must be counteracted by 
paying attention to what has before been neglected. Chil- 
dren thus affected must be strictly treated, but they require 
some slight preliminary purgation to clear away indigestible 
and improper material from the intestinal canal. For this 
purpose Formula 1 1 is a serviceable one, and not unpalatable. 
A teaspoonful to a tablespoonful of fluid magnesia may be 
given instead, if preferred, twice or three times in the day ; 
and for a more active aperient a small teaspoonful of liquorice 
powder or a piece of a Tamar Indien lozenge may be given. 
Subsequently a little sulphate of magnesium may be com- 
bined with sulphate of iron, as such children are often 
anaemic, and require iron (F. 21). 

In the prolapsus ani, that is often present in such cases, I 
have never found it necessary to do more than support the 
parts by strapping the buttocks tightly together by a broad 
band of strapping, encircling the hips round the great 
trochanters ; and, in the worst cases, giving an enema of 
sulphate of iron and cold water, a drachm to the half-pint, 
and a third part to be used at a time every morning, or 
morning and evening, for a few days. More severe measures 
are sometimes spoken of, but the circumstances under which 
they can be called for must be very exceptional, and I have 
never seen a case where they were necessary. For the 
u nervous diarrhoea" nothing acts so well as small doses of 
Dover's powder. It is a disease particularly of children 
five to ten years old. Two, two and a half, or three grains 
may be given three times a day in a little milk, and an hour 
or so before meals. A little liquid extract of opium may 



84 THE DISEASES OF CHILDREN. 

be given in fluid magnesia, with sulphate of iron, as a useful 
way of combining the opium with a tonic, and at the same 
time avoiding any too costive effect. The iron is precipi- 
tated as green carbonate, but this does not in any way 
impair the effect. (F. 22.) Easton's syrup in doses of 
twenty or thirty drops three times a day, may be given 
afterwards (syrupus ferri et quiniae et strychniae phos- 
phatum). It is better than the more usually prescribed 
Parrish's food under these circumstances, being less liable 
to upset the stomach. 

[Lienteric diarrhoea does not yield to ordinary astringents, 
and is much increased by laxatives, as castor oil. Opium 
checks it temporarily, but the best remedies are Fowler's 
solution and tincture of nux vomica in small doses. At 
the same time a digestible diet must be ordered at regulated 
intervals.] 

Chronic diarrhoea in infants requires the expenditure of 
much thought and trouble if the treatment is to be suc- 
cessful. It is often obstinate, and improvement even in 
favorable cases very fitful. The treatment comprises diet, 
general hygiene, and medicine. The diet must be regulated 
upon the lines already laid down for children in health. 
Chronic diarrhoea is so much a disease of bad or too abun- 
dant feeding, that the first duty will probably be to see that 
starch is eliminated from the diet, or that milk is taken in re- 
duced quantities. If milk should disagree, as it is liable to 
do even when diluted largely with water, or lime-water, milk 
and barley-water may be tried, and then whey or thin veal 
broth. But whatever is given must be in very small quan- 
tities, sometimes only a few teaspoonfuls, so as, if possible, 
to allow of digestion without starting the intestines into 
muscular action. If under these circumstances the child 
gains in weight, and the motions become more colored with 
bile and more consistent, it will probably get well ; but the 



DIARRHOEA. 



85 



food must be carefully regulated, and only slowly increased 
in quantity. As the gastro-intestinal tract becomes more 
tolerant, so the quantity of food given may be increased, 
the frequency of the meals decreased, and milk food be 
gradually reintroduced. In the worst cases all food must 
be stopped, and raw meat given instead. The directions 
given by Trousseau are as follows : Take a lean piece of 
beef or mutton, and after cutting it into small pieces, reduce 
it to a thick pulp with pestle and mortar. The pulp so 
made is passed through a fine colander, which will allow 
nothing to pass save the juice of the meat and fibrinous 
matter. This is scraped from the external surface of the 
colander, sweetened ; and, to begin with, a teaspoonful may 
be given three times a day; the quantity being gradually 
increased till five or six ounces may be taken in the course 
of the twenty-four hours. 

It will often be found, however, that, except for the 
youngest infants, who take raw meat with avidity, it creates 
disgust, even when well sweetened. It is then to be given 
stirred up in a little cold veal broth or thin barley-water. 
It will usually be readily taken in this way when refused as 
a pulp. If not, it may be made into small masses, with 
confection of roses or currant jelly, or it may be mixed 
with chocolate made with water. At first the meat appears 
unchanged in the stools, but this soon alters ; the meat 
becomes partially and then entirely digested, and the child 
gains in weight in proportion. 

In what may be called general hygiene, the child must be 
kept warm and clean. It should be wrapped in flannel and 
carefully guarded against cold feet and a cold stomach. It 
should be kept in one temperature, but in as pure air as 
possible, and all soiled linen should be removed from it at 
once. Medicines are comparatively of less value. They 
are by no means to be omitted, but careful diet and warmth 

8 



86 THE DISEASES OF CHILDREN. 

are the essentials. Of drugs, opium is the most generally 
useful, and this may be well combined with logwood, ipe- 
cacuanha and chalk, as in the mistura haematoxyli co. of 
the Guy's Hospital Pharmacopoeia. (F. 23.) A teaspoonful 
should be given every four hours if the diarrhoea is profuse, 
and less frequently according to circumstances. Another 
useful remedy is bismuth. 

Sometimes astringents are useful — gallic acid, sulphate of 
copper, acetate of lead, may any of them be used according 
to the formulae given. (F. 25, 26, 27.) [Nitrate of silver is 
a most useful drug when the diarrhoea proves obstinate, 
aphthae appear in the mouth, and there is much thirst and 
prostration. One twenty-fourth of a grain may be given, 
suspended in syrup of acacia, every two hours to a child 
of two years. Stimulants are also necessary to relieve the 
tendency to prostration. Whiskey is the best, and it must 
be given in doses and at intervals proportioned to the de- 
mands of the individual case. Ten drops every two hours 
is about the average initial dose.] 

Astringent enemata are recommended by some. They 
are not often retained, and are but seldom of use. Nitrate 
of silver, one grain to five ounces of water, is recommended 
by Trousseau ; but on the whole I am inclined to prefer 
equal parts of an infusion of ipecacuanha and decoction of 
starch ; or, starch and tincture of opium — two or three 
drops of the latter to two ounces of the vehicle. 

[Injections of nitrate of silver, which by the way are very 
serviceable, should be given at intervals of twelve hours 
and preceded by an enema of warm water to wash out the 
rectum. After being continued for forty-eight hours, they 
should be discontinued for a day, during which the patient 
may receive, at the same intervals, injections of tincture of 
opium in starch water, three drops to half a fluid ounce at 
the age of two years. 



DIARRHOEA. 87 

When improvement sets in tonics must be employed to 
build up the general health. One of the best to succeed 
the treatment directed especially to the relief of the diarrhoea 
is the solution of the nitrate of iron with a mineral acid, 
for example : 

R. Liquor. Ferri Nitratis, 

Acidi Nitrici Dil., aa f £ss. 

Syrupi Zingiberis, . . . . . . f §j. 

Aquae, q. s. adfgiij. M. 

S. One teaspoonful three times daily, for a child of two years.] 

Dysentery. — This term is applied in England sometimes 
to chronic ulceration of the colon, sometimes to acute in- 
flammation with the formation of diphtheritic membrane. 
In either case it is a disease which rarely attacks children, 
and does not differ from such affections in an adult. Ex- 
tensive ulceration of the colon is almost always due to 
tubercular ulceration, though it is possible that it may be 
an occasional result of chronic diarrhoea. I have only once 
seen a case of acute colitis. The patient was a girl, aged 
eleven and a quarter, who had been living badly. She was 
extremely prostrate, pale, and covered with a purpuric 
eruption. Her temperature was 100.8 . The spleen large. 
The bowels were confined at first, but the evacuations soon 
became watery, and pink from the presence of blood, and 
she sank rapidly; the temperature rising to 105.6 . The 
blood showed a reduction of more than one-half of the 
corpuscles and 65 per cent, of the coloring matter. At the 
inspection, the lower part of the colon and the rectum were 
the seat of a severe diphtheritic inflammation. The mucous 
membrane was swollen, coated with thick adherent mem- 
brane, the surface beneath being ecchymosed and bleeding. 

Such cases, when they occur, must be treated, like bad 
cases of acute enteritis, by careful nourishment, stimulants, 
the dilute mineral acids, quinine, etc. For chronic ulcera- 
tion the treatment of chronic diarrhoea will apply. 



88 THE DISEASES OF CHILDREN. 



CHAPTER V. 

STOMATITIS— THRUSH— CANCRUM ORIS. 

Stomatitis. — Four or five different forms of stomatitis 
have been described, but no useful purpose is gained by 
such elaboration. It will be sufficient to treat of — I. Stoma- 
titis ; 2. Thrush; 3. Cancrum oris. Stomatitis and thrush 
are often combined. 

I. Stomatitis. — Children thus affected are brought with 
the complaint that their breath is offensive, that they are 
spitting up blood, or that blood stains their pillow during 
sleep. It is a disease chiefly of the lower classes, which 
affects boys and girls of any age from two to nine or ten 
years, and perhaps is more common in the months of 
March, April, and May than at other seasons of the year. 
It has been supposed by some to be due to a milk diet, but 
this I have not been able to substantiate; nor is it easy to 
prove that it bears any particular relation to dentition; but 
so far as my own statistics go it would appear to be more 
common between the ages of two and three and seven and 
nine. Henoch puts it as most common between the ninth 
month and the middle of the third year, but has observed 
it not seldom in older children, and he considers dentition, 
both first and second, to have much to do with its occur- 
rence. It occurs in varying degrees of severity, of which I 
may give examples. 

1. The common form is a superficial ulceration of the 
edges of the gums, the tongue, and the cheeks ; the gums 
being vascular, and fringed with a yellow margin of decay- 
ing granulations. 



STOMATITIS — THRUSH CANCRUM ORIS. 89 

E. L., a girl aged nine, had had a sore mouth, with some 
malaise, for a fortnight. There was superficial ulceration 
of the gums, mostly in the lower jaw, running along the 
line of junction of the gum with the teeth. From this there 
was an offensive sanious discharge. A few circular pus- 
tular-looking ulcers were present on the mucous membrane 
of the cheek, and some on the sides, tip, and dorsum of the 
tongue. 

In young children this condition may be accompanied 
with considerable elevation of temperature (102 — 103 ), and 
I have sometimes thought, from the correspondence of the 
13/sis with the commencement of rapid healing of the ulcers 
and the disappearance of the fur from the tongue, that pos- 
sibly some cases at any rate might be due to some specific 
germ. 

2. Small circular ulcers are scattered over the tongue and 
mucous membrane of the cheeks. 

E. H., a boy aged three years. The tongue was thickly 
coated, and numerous small circular ulcers with sharp vas- 
cular margins occupied its sides and the inner surface of 
the lips. The pulse and temperature remained normal. 

3. As a large more or less deep sloughing ulceration of 
the cheek, but not accompanied with much lividity or sur- 
rounding induration. 

S. A., a girl aged six, had been out of sorts for a month. 
The bowels were confined, with cough and collicky pains 
in the abdomen. A large unhealthy looking gray slough 
occupied the greater part of the inner surface of the right 
cheek. The gums were ulcerated all round the mouth, and 
many of the teeth were loose. The tongue was superfici- 
ally ulcerated. 

Ulcers of this kind are generally of very irregular surface, 
owing to their size, the superficial swelling, and the pressure 
of the teeth against them. For the same reasons they cause 



90 THE DISEASES OF CHILDREN. 

a good deal of pain to the child in eating, the swollen sur- 
face getting between the teeth. They may in this way 
retard recovery by rendering the child unwilling to take a 
proper quantity of food. They are usually as amenable to 
treatment as other kinds, but the teeth are liable to become 
loose ; occasionally a small piece of bone from the alveolus 
may exfoliate, and I have once seen cancrum oris follow 
what I considered to be this form of ulceration at the outset. 
The child came at first as an out-patient to the Evelina 
Hospital, and was admitted to Guy's Hospital a day or two 
after with the major disease. West mentions the possibility 
of such an occurrence, but considers it one of rarity. 

[It is better, perhaps, to divide these affections of the 
mouth into three classes, namely, catarrhal stomatitis, aph- 
thous stomatitis, and ulcerative stomatitis. 

Catarrhal stomatitis consists of an erythema of the mu- 
cous membrane of the mouth, either limited to circum- 
scribed spots or extending over the whole surface. In the 
latter case there is much swelling. The papillae of the 
tongue are enlarged and reddened and its epithelium is 
abraded, while the mucous glands of the lips and cheeks 
are prominent and yield on pressure a drop of mucus. The 
buccal secretion is increased in quantity, acid in reaction, 
thin, or viscid and flocculent, and runs from the mouth, pro- 
ducing excoriations of the skin of the lips and chin. The 
mouth is hot and tender, sucking or mastication are painful 
and cold drinks are craved. The bowels are apt to be dis- 
turbed. 

This condition is produced by hot and irritating food, 
teething, carious teeth and want of cleanliness ; it may also 
arise in the course of the exanthemata, or precede and attend 
more serious affections of the mouth. 

The treatment consists in keeping the mouth clean by 
frequent applications of tepid water, lancing the gums in 



STOMATITIS — THRUSH — CANCRUM ORIS. 9 1 

difficult dentition, removing carious teeth, applying a wash 
of borax or chlorate of potassium, and attending to the 
digestion both by diet and appropriate medicines. 

Aphthous stomatitis. — In this affection a number — three or 
four to twenty or more — of small ulcers appear upon the 
reddened and swollen mucous membrane of the lips, cheeks, 
tongue and gums. They are round or oval, usually from 
one to two lines in diameter, scarcely depressed, with a 
yellowish white floor and surrounded by a narrow ring of 
deep redness. Sometimes several of them run together, 
forming large irregularly shaped ulcers. No cicatrices are 
left on healing. 

The mouth is hot and tender, the tongue is heavily 
frosted, the flow of saliva is greatly increased, and this fluid, 
now acid in reaction, as it dribbles over the parted lips, 
excoriates the skin with which it comes in contact. Appetite 
is diminished, partly on account of the pain incident to 
sucking or mastication and partly in consequence of asso- 
ciated gastric catarrh ; cold water is taken freely. There 
is moderate heat of skin, a tendency to constipation, restless 
sleep and irritability of temper. 

Aphthae occur in the course of gastro-intestinal catarrh 
from improper feeding, during dentition, or with measles, 
scarlet fever, whooping cough and other acute diseases of 
infancy. The affection is most common between the sixth 
and fourteenth month of life, and large crops of cases are 
apt to arise together. 

The general treatment comprises careful regulation of the 
diet and a moderate dose of calomel, followed by pepsin 
with dilute muriatic acid if there be much gastric distur- 
bance, or by chlorate of potassium and dilute muriatic acid 
if the oral symptoms predominate. Locally a wash of 
chlorate of potassium (gr. x to f Si) should be used every 



92 THE DISEASES OF CHILDREN. 

hour, and if the ulcers do not heal quickly they may be 
touched once a day with a point of lunar caustic. 

Ulcerative stomatitis has for anatomical lesions paren- 
chymatous inflammation of the gums (ulitis) and ulcerative 
destruction of the investing mucous membrane. The lower 
jaw is more frequently affected than the upper. 

First the mucous membrane becomes red and swollen, 
the portions of the gums between the teeth standing out 
like little flasks and bleeding on the lightest touch. Next 
the edges in contact with the teeth turn yellow or yellowish- 
gray, the tissue softens and gradually breaks down into 
superficial linear ulcers, having gray floors and red margins. 
The teeth are loosened, and sometimes the periosteum is 
destroyed and necrosis of the jaw-bone takes place. After 
a time the ulceration extends to the cheeks, the lips and the 
tongue, and occasionally true noma follows. 

The mouth is hot, the tongue coated, the breath offensive, 
and streams of viscid blood-stained saliva drivel away. 
There is much pain on mastication, and upon this, in great 
part, depends the anorexia. The submaxillary and lym- 
phatic glands of the neck are usually swollen, and the face 
is often cedematous. Debility, fretfulness, and disturbed 
sleep are symptoms, but the implication of the general 
system is trifling. The course is indefinite. 

Ulcerative stomatitis is most prone to develop in feeble, 
rickety and strumous children, in those who are exposed 
to bad hygienic influences, and in those convalescing from 
typhoid fever, measles, and scarlatina. It is never seen 
before the appearance of the teeth, but may occur at any 
age thereafter. It is not contagious, though large numbers 
of cases are apt to arise simultaneously. The plan of treat- 
ment is to improve the diet and general hygienic conditions, 
to administer tonics and stimulants, to keep the mouth clean 



STOMATITIS — THRUSH — CANCRUM ORIS. 93 

and to make frequent applications of a solution of chlorate 
of potassium.] 

The treatment of stomatitis is not usually one of much 
difficulty. When the ulceration is extensive and deep upon 
the cheek, the mere size of the ulcer requires time for its 
closure; and a corresponding ulcer on the tongue, which 
is not unfrequently present, and is probably due to direct 
inoculation, may prove a little troublesome. But as a rule 
the exhibition of chlorate of potassium is followed by cure 
within a few days. The subjects of stomatitis are usually 
somewhat out of sorts ; as soon, therefore, as the mouth 
will bear it the chlorate of potassium may advantageously 
be combined with a tonic of hydrochloric acid and tincture 
of cinchona. (F. 28.) 

When the ulceration is considerable the ulcerated surfaces 
should be freely swabbed by the medical attendant with a 
saturated solution of permanganate of potassium. Two ap- 
plications of this kind, at intervals of two or three days, are 
generally sufficient; but, if practicable and necessary, such 
an application might be made daily, and a gargle of the 
ordinary Condy's fluid, half a teaspoonful to a pint — or a 
teaspoonful of the pharmacopceial lotion — should be used 
frequently, either by syringe or gargle as the age of the 
child may require. Loose teeth should not be extracted 
until a chance has been afforded them of refixing.themselves 
in their sockets, or until it is evident that their presence is 
prejudicial to the healing of the sores. 

2. Thrush is a fungus which grows upon the buccal 
mucous membrane and occasionally extends to other parts 
of the digestive tract, such as the oesophagus, the stomach, 
and intestines. The oidium albicans is the name by which 
it has long been known, but Gravitz has called in question 
the previous descriptions,* and has shown that it belongs 

* " Zur Botanik der Sorrs," Deutsche Zeitschr. f. Prakt. Med., 1877, No. 20. 



94 THE DISEASES OF CHILDREN. 

to the wide-spread moulds, and is identical with the mould 
of wine. It consists of long-jointed threads and spores, 
which, like tinea upon the skin, are sometimes entangled in 
the epithelium only, ahd sometimes run down in the folli- 
cles. Like tinea, it appears to be contagious. Its frequent 
presence in the mouth is thought to be favored by the acid 
reaction which so often obtains there. It is generally held 
to be a form of stomatitis, but it is not necessarily so. To 
many cases of stomatitis, thrush is superadded. The thrush 
fungus may no doubt itself be a cause of stomatitis, but it 
may and does exist without any appreciable inflammation 
whatever. Tinea of the scalp may exist without exciting 
any inflammation, and thrush likewise. It is thus that two 
groups of cases are met with in practice, those in which 
there is no inflammation, when the disease is readily curable, 
and those in which there is more or less inflammation, and 
where it is dangerous either in itself or as indicating a 
wide-spread disorder of the digestive tract associated with 
feeble energy. 

In the first group the affection is prone to attack infants 
within the first month of birth — the small and spare ones of 
infancy, who take to the breast badly or are being fed arti- 
ficially. Looking into the mouth, a layer of thin white 
membrane is seen covering the arch of the palate ; perhaps 
a little similar material is dotted in opaque white specks 
over the sides of the tongue — the mucous membrane around 
being quite pale and free from inflammatory action. Under 
the microscope the white layer is found to be composed of 
oil globules from the milk, squamous epithelium, and the 
spores and mycelium of the fungus. A better adapted diet 
— often in the direction of a little added cream — and the 
frequent application of the glycerinum boracis to the affected 
parts, will cure the disease. The mouth should be carefully 
wiped out after each meal with soft rag or well-wetted wool, 



STOMATITIS — THRUSH CANCRUM ORIS. 95 

and the glycerinum boracis applied afterwards in the same 
way. Cases are on record in which the contagion appears 
to have been conveyed from one child to another by means 
of spoons, bottle-nipples, and such like ; and though it is 
doubtful whether vigorous children are liable to be contami- 
nated either with tinea or thrush, the possibility of such a 
thing should enjoin the most scrupulous cleanliness. 

In the graver cases, which the second group comprises, 
dryness and injection of the mouth are superadded ; the 
papillae of the tongue are prominent and vascular, and the 
fungus occupies a larger area and is of more luxuriant 
development. The dorsum of the tongue will be more or 
less covered, and the lips, cheeks and edges of the tongue 
are also affected with milky-white points of the growth. 
Superficial ulceration is also often present. 

In all cases of thrush, but in these bad cases more es- 
pecially, there is a liability to an erythematous rash, or even 
a superficial dermatitis, about the buttocks and genitals. 
Mothers are fond of telling that their children have had the 
thrush, and that " it has gone through them " — a popular 
impression which, although not wholly true (for it is but 
rarely that the fungus is present about the anus, or even in 
the intestines), is probably not altogether erroneous. 

What actually happens is probably this : The presence 
of thrush indicates a disordered state of the secretions of the 
mouth. The state of the tongue and faucial mucous mem- 
brane is, to some extent, an indication of disorder all along 
the gastro-intestinal tract with which erythema, intertrigo, 
eczema, or superficial dermatitis, by whatever name the dis- 
ease may be known, is associated. This is supposed to be 
due to acrid discharges from the bowels and to abnormally 
irritating qualities of the urine. But I am disposed to think, 
from the nicety and rapidity with which its recurrence can, in 
some children, be controlled by the regulation of the starchy 



96 THE DISEASES OF CHILDREN. 

matters in the food, that it is in all probability a general 
blood condition, which appears in those parts where local 
conditions — such as warmth, moisture, and irritation — favor 
its outbreak. 

There may be some fever with this form of the disease. 

Severe thrush is usually a sequela of chronic diarrhoea or 
vomiting, prolonged starvation, and pyrexia of all kinds — 
but particularly when associated with gastro-enteritis and 
dentition. It may also present itself after any severe illness, 
such as any of the exanthemata may produce. This form 
of the complaint denotes extreme exhaustion, and the 
general condition rather than the local state calls for treat- 
ment. It is, moreover, a case rather for dieting than for 
drugging. The details must be suited to the special circum- 
stances ; but as a general principle it is not too much to say 
that the body-heat requires careful attention, and is to be 
kept up by all possible means. The food must be nutritious, 
and given frequently in small quantities. Stimulants, such 
as brandy or rectified spirit, in twenty-drop doses every 
three or four hours, are generally most beneficial. No care 
is too exhaustive for such cases. The directions for food, 
stimulants, drugs, etc., should all be written precisely on 
paper, and frequent visits should be made during the day to 
insure that they are intelligently carried out. 

In addition, small doses of carbonate of ammonium or of 
chlorate of potassium should be given (F. 28) every three 
or four hours, and the glycerinum boracis be applied fre- 
quently, as before described. 

3. Cancrum Oris, Noma, or Gangrenous Stomatitis is 
characterized by the appearance of an indurated swelling in 
the cheek, which rapidly extends and mortifies, perforating 
the soft parts, and, if unchecked, destroying all the tissues 
within its reach. In this way a circular eschar is produced 
in which the entire cheek may disappear ; the ulceration 



STOMATITIS — THRUSH — CANCRUM ORIS. 97 

extends into the orbit or on to the neck, the underlying 
bone being killed and the teeth dropping out. The disease 
commences on the inner surface of the cheek as a livid, red, 
painful induration, which soon extends through its entire 
thickness, and appears externally, the skin becoming red, 
tense, and shining. The area of redness gradually extends, 
the parts around become cedematous, and the central part 
gangrenous. An irregular ulcer is now seen in the centre 
of the affected mucous membrane, covered with a gray or 
yellowish-gray slough, which, by means of lateral and deep 
extension, rapidly kills all the soft parts, and ultimately 
produces a circular perforation in the cheek. The disease 
often appears to undergo a temporary arrest, but only to 
begin again shortly in the edges of the ulcer. The indu- 
rated swelling makes the opening of the mouth a difficulty, 
and there is copious dribbling of fetid saliva. The gan- 
grenous aspect of the sore, the blackened teeth showing 
gums beneath, and the excessive fetor, conspire to make a 
picture so repulsive that even the death of the child — which 
hitherto has resulted in over 75 per cent, of the cases — adds 
but little to its intensity, and comes in most cases as a wel- 
come relief. After the formation of the slough there would 
appear to be but little pain attending it; the child is usually 
prostrate and lethargic. 

The constitutional symptoms are not always alike. Oc- 
curring as it does so often in anaemic and exhausted children 
after measles and such like, malaise and fever (101 to 104 ), 
though usually present, may be overlooked ; and the drib- 
bling of fetid saliva and the livid induration of the cheek 
are the first signs to attract attention, the child soon after 
becoming prostrate and drowsy. But it occasionally hap- 
pens that the gangrene may progress even to the destruc- 
tion of the greater part of the cheek, the child all the while 
sitting up and playing with its toys ; in such case the fatal 



:S THE DISEASES OF CHIIX5 

result may be due to the poisonous exhalations which the 
child breathes — perhaps to the putrid saliva which it swal- 

L:~.vs. In ?. niinrrir." :: :ast5 :he 5.:.:r-.n~ -: ;5 :: .5 
arrested by treatment ; the edges of the ulcer granulate, and 
the child recovers. It is worthy of note that when this 
happens the gaping wound left by the gangrene will contract 
to very small dimensions ; but the perfection of the cure is 
somewhat marred by the frequent occurrence of corre- 
sponding distortion of the angle of the mouth, or the lower 
eyelid — or, by the inconvenience caused by adhesion of the 
:hi::: :: :he j:::. :r : :nes. 

Morbid Anatomy. — But little can be added to the clinical 
history. A black-edged, foul-smelling ulcer extends over 
more or less of one cheek. Its base is formed by what re- 
mains of the gangrenous tissue of the cheek, by remnants of 
gum tissue, necrotic jaw, and discolored and even ulcerated 
tongue. The soft parts being so extensively involved in the 
sloughing process, and having, in addition, usually received 
a copious dressing of some strong escharotic, are not in a 
state favorable to any minute examination ; but, so far as I 
have seen, there is comparatively little accessory oedema of 
the parts surrounding the disease after death ; nor need 
there be any formation of purulent thrombi in the facial or 
other veins of the neck ; but abscesses in the lungs and 
:iia from this source are occurrences which are not 
:r.:re:uer.:. :.r.i s:.:...i z- re:: f niberei :.:\i szi.rz'r.zi :::. 
Rilliet and Barthez describe the neighboring lymphatic 
glands as enlarged. The swelling is not usually great, but 
they may be considerably injected. I should be inclined, 
:::;:::. :: r.\:.\<z :-. ::r.:r.vf: :::■•:::: i\\t ::::rb:i :.z zz:.r?.:.zzs 
of facial carbuncle and those of the disease we are discuss- 
ing, in this way, that the former is associated with much 
frr: „i :z.~.::\:::\ :.:.:. z-~:.±~zy :: cur :'tn: :;:r:~b : -is. :he 
latter not. In most cases there is a diffused form of bron- 



STOMATITIS — THRUSH CANCRUM ORIS. 



99 



cho-pneumonia about the root and bases of the lungs, and 
death is caused by a lesion of this kind, or by the drowsi- 
ness and exhaustion to which allusion has been made. 

Etiology. — The most important fact which has been ob- 
served under this head is that in so large a proportion of 
cases measles has preceded it. Scarlatina, typhoid fever, 
diphtheria, unwholesome living of all kinds, share — but to 
a comparatively slight extent — the bad name which attaches 
to measles ; and German authors insist also upon the fre- 
quency of its occurrence after the administration of mercu- 
rials. West records one such case out of ten ; but it is 
probably not a frequent occurrence in England. 

The disease may occur at any age between two and twelve 
years, but it is most common from two to five ; and more 
common, according to Vogel,* in girls than in boys. 

Treatment. — The great fatality attaching to cancrum oris 
must not lead us to a desponding neglect of its treatment ; 
on the contrary, there are certain cardinal aims to be sought, 
which, though difficult of achievement, are not, let us hope, 
impossible or impracticable, and which, if they can be 
attained, may lessen the mortality. It has been held by 
most writers up to the present time that the disease is a 
constitutional blood condition, not a local one, and the 
evidence of this has been sought and found in its occur- 
rence after the exanthemata and in the broncho-pneumonia 
and occasional pyaemia which usher in death. But states 
of exhaustion are just those in which nowadays risks of 
local contagion are considered paramount. It could be 
shown, from numerous inspections, that severe operative 
procedures about the mouth, such as removal of the tongue, 
gangrenous ulcers about the throat, etc., are particularly 
prone to be followed by a gangrenous form of broncho- 
pneumonia. And it is only too obvious that in these cases, 

* " Lehrbuch der Kinderkrankheiten," 1880, p. 90. 



IOO THE DISEASES OF CHILDREN. 

as in cancrum oris, there is a direct probability of the 
transferrence of septic matter along the respiratory passages. 
Lastly, the occurrence of abscesses in the lungs, if not ex- 
plicable in this way, is intelligible as resulting from direct 
transmission of septic matter along the branches of the 
external jugular vein to the right side of the heart and the 
lung. 

Thus, then, all these features of the disease admit of inter- 
pretation by means of some virulent local poison. But let 
me draw attention to another point in its history, which is, 
I think, suggestive also in this respect. I have alluded to 
the fact that the gangrene of the face may produce very 
extensive destruction whilst yet the child is at play with its 
toys, eats and drinks well, and appears but little affected. 
In this respect these cases bear some resemblance to some 
cases of charbon. Like charbon also, it is a disease in 
which micro-organisms have been found in the blood,* 
although, at present, in but a small number of cases, and 
from the same disease some encouragement is derived to 
persevere in local treatment, for it has been found by my 
surgical colleagues at Guy's Hospital that the early and 
vigorous local treatment of anthrax offers a fair chance of 
cure. I need only add that all writers have hitherto con- 
tinued to recommend local treatment, although it has not 
been attended with any remarkable success. 

But as regards success, a disease so desperate requires no 
less stringent remedies, and between the one and the other 
it is not to be wondered at that a delicate child often suc- 
cumbs. Nevertheless, such success as is possible can only 
be obtained by constant attention to two points: I. The 

* " On a Case of Noma in which Moving Bodies were observed in the 
Blood during Life," by A. E. Sansom, M.D., F.R.C.P. ; Medico-Chir. Trans,, 
1878, vol. lxi., p. I. 



STOMATITIS — THRUSH — CANCRUM ORIS. 



IOI 



destruction of the local virus ; 2. The prevention of the 
passage of fetid matter into the respiratory passages. 

Upon the first head I have nothing new to say. I can 
only repeat that in anthrax, which has many features of 
similarity, the disease has been treated early by free excision 
and subsequent cauterization, and in several instances with 
success. That appears to be the recognized practice for all 
such cases at Guy's, and I should strongly recommend a 
similar procedure for cancrum oris, and insist upon its early 
application. Supposing, as is common, that gangrene has 
already commenced, and the disease has gone too far for 
excision to be practiced, all possible sloughing material 
should be removed, and the surfaces together with the 
edges of the ulcer freely cauterized — either by strong nitric 
acid, or by one of the many convenient forms of cautery 
now in use — and then afterwards dusted with iodoform. 

The passage of foul material into the air-passages may be 
at any rate partially controlled by keeping the child on its 
stomach, inclined to the affected side, and the head depen- 
dent over a pillow. The saliva and discharges tend thus to 
run outwards rather than backwards. The diseased part 
must then be frequently and freely smeared with some 
tenacious disinfectant, such as terebene, oil of eucalyptus, 
or iodoform ointment, and frequently syringed with a lotion 
of chlorinated soda. Should these, various remedies seem 
unsuccessful, I am not sure that it would not be better to 
perform tracheotomy, and thus allow of respiration below 
the sources of contagion, rather than run the risk of broncho- 
pneumonia, so all but certain as it appears to be. Twenty- 
eight fatal cases are mentioned by Dr. West from his own 
practice and that of MM. Rilliet and Barthez, no less than 
twenty-five of which died from broncho-pneumonia. 

While these measures are adopted the child's strength 
must be kept up by the administration of nourishing liquids 

9 



102 THE DISEASES OF CHILDREN. 

and stimulants. Should there be any difficulty in introduc- 
ing them by the mouth, they may be given by a tube or 
catheter passed through the ulcer, or even along the floor 
of the nose. As a last resource, enemata may be used, 
recourse being had to artificial digestion of the fluids in- 
jected. Chlorate of potassium and iron should if possible 
be given by the mouth. 

Ulceration of the mouth is also met with under other 
circumstances, of which syphilis and whooping-cough may 
claim special mention. Syphilis in children may be either 
congenital or acquired. Acquired syphilis is rare, but when 
it occurs it may be associated, as in the adult, with consider- 
able soreness and superficial ulceration of the tongue, and 
with mucous tubercles about the angle of the mouth. 

Here is such a case : A boy, aged six, who had never had 
any previous illness, had complained of pains in his limbs 
for a fortnight. He had enlarged cervical glands, a macular 
syphilide all over the trunk, and injection of the fauces with 
ulceration of the left side of the uvula. There were condy- 
lomata about the scrotum and anus. His mother had had 
an ulcerated throat ; but no other source for the inoculation 
could be traced ; nor was there any evidence of a chancre. 
He was treated with gray powder, the condylomata being 
dusted with calomel, and he rapidly improved, save that, 
temporarily, he lost a good deal of his hair. 

Congenital syphilis in its later phases is apt to show 
itself by intractable ulcers about the tongue, mouth, or 
palate. 

Thus, a boy, aged four, who had snuffles badly when a 
child, was brought for a serpiginous ulcer on the dorsum of 
the tongue, the centre of which was raised and warty. The 
ulcer slowly healed under iodide of potassium and iodide 
of iron. He was also suffering from syphilitic choroiditis 
and retinitis pigmentosa. In another boy a large ulcer de- 



STOMATITIS — THRUSH — CANCRUM ORIS. 



103 



stroyed the fraenum linguae, and covered part of the floor of 
the mouth. 

In another case, a girl, aged twelve, with depressed nose, 
thick alae nasi, fissured lips, and pegged teeth, had a deep 
perforating ulcer of the hard palate, and ulceration of the 
right pillars of the fauces. Sometimes as in adults, the 
whole of the soft palate is destroyed, the part becoming 
cicatrized, and the thickening extending to the fauces and 
larynx. 

Treatment. — All such cases, whether due to acquired or 
congenital syphilis, should be treated by murcurials. A 
grain or two grains of the hyd. c. cret. may be given once 
or twice a day, or mercurial inunction may be employed if 
the child is quite young. In the late ulcer of congenital 
syphilis, a grain of the iodide of potassium with iodide of 
iron may be given as well, and occasional applications of 
nitrate of silver may also be necessary. 

Ulceration of the Fraenum Linguae in Whooping-cough. 
— This is a very frequent occurrence in the convulsive stage 
of pertussis, and a good deal of attention has been directed 
to it of late years ; but except noting its occurrence, there 
is not much to be said of it. It is usually a shallow sharp- 
edged ulcer, situated on the fraenum close under the tongue, 
and often has a yellowish surface. It appears to be in some 
way associated with the presence of the two lower central 
incisor teeth, as it is never found unless they have been cut. 
It is therefore most probably due to the friction of the 
tongue over their edges when the cough is severe or fre- 
quent. It is said by Vogel to be most frequent between the 
ages of one and two years, and that it but seldom occurs in 
older children ; this may possibly be explained by some 
differences in the sharpness of the cutting edges of the teeth 
from wear. 



104 THE DISEASES OF CHILDREN. 

The ulcer heals spontaneously after a time, and does not 
usually require treatment. 

Hypertrophy of the Tongue occurs occasionally. It is 
congenital, and is usually associated with imbecility and 
other evidences of abnormal development, either excessive 
or stunted, such as together make up the condition called 
cretinism. When extreme it causes early death by suffoca- 
tion. But to a moderate degree, it need not interfere with 
either respiration or deglutition, and children of one or two 
years old may be met, with a fleshy mass visible between 
the teeth of the half-open mouth which characterizes this 
hideous deformity. 

Hare-lip and Cleft-palate also require mention, because 
in infant life they interfere seriously with sucking. Special 
india-rubber-nipples are now made with an obturator, as it 
is called, or flat piece of india-rubber, above them. This 
contrivance, though rather clumsy when put into the mouth, 
fills up the cleft in the palate, and allows suction to be 
carried on, and by this means many infants can be reared. 
Sometimes artificial feeding can be successfully effected by 
carefully regulating the flow of milk through a siphon of 
india-rubber tubing ; sometimes slow and laborious spoon- 
feeding alone answers ; and sometimes nothing succeeds, 
and the child wastes. These are cases which often require 
the expenditure of considerable ingenuity and thought to 
combat the many incidental peculiarities which occur. In 
hare-lip an operation should be resorted to if the difficulty 
in taking food cannot be otherwise overcome. In cleft- 
palate operative measures are not admissible till the fourth 
or fifth year of life. 



DISEASES OF THE DIGESTIVE TRACT. IO5 

CHAPTER VI. 

DISEASES OF THE DIGESTIVE TRACT. 

Diseases of the Tonsils and Pharynx. — Acute tonsillitis 
is not a common disease of childhood, if quinsy in adults 
be taken as the standard of comparison. I have, however, 
lately had a girl of six under treatment who was admitted 
for a large and very deep punched-out ulcer on the left 
tonsil, w T hich could, I think, only have originated in acute 
suppuration of the tonsil, and a consequent slough of its 
anterior part. It was so deep that, afraid of hemorrhage, I 
admitted her. It speedily healed under tonic treatment and 
the local application of boracic acid and glycerine. 

But a less acute form of disease is very frequent. In this 
the child complains of headache, refuses its food, perhaps has 
a little pain in swallowing, and the temperature rises quickly 
to ioo° or 102 . Henoch notes the occasional occurrence 
of convulsions, but this is very rare. The tongue is furred 
and often red at its edges. The tonsils are swollen, the 
whole of the fauces are brightly injected, and, perhaps, one 
begins to think of scarlatina. But no rash is visible, nor is 
there much enlargement of the glands, and probably the 
case is left as one of doubt, with the prescription of a gentle 
purgative of some sort, and the enjoinder of warmth, and a 
light diet for the next few hours. Soon the bowels act, the 
temperature falls, and within a day or two the child is well 
again — with, maybe, a little undue pallor and want of its 
accustomed energy. Some children are peculiar in exhibit- 
ing a tendency to the recurrence of such attacks, just as 
some have a tendency to the recurrence of bronchitis or 
pneumonia, but cast it off as they grow older. 



IC6 THE DISEASES OF CHILDREN. 

In another set of cases the tonsils are more exclusively 
involved ; they are red and swollen, and upon one or both 
are numerous yellowish-white spots of inspissated secretion 
from the follicles. Sometimes these spots coalesce to form 
more or less of a definite layer which puts on some of the 
appearances of the membrane of diphtheria. This form of 
disease, perhaps even more than the former, is associated 
with mild symptoms ; and the swelling of the tonsils with 
exuding secretion may often be met with as a temporary 
occurrence, with hardly any appreciable alteration in the 
child's health, when the tonsils are the subject of chronic 
hypertrophy. Acute ulceration of the tonsils is not un- 
common in children as the result of bad hygienic conditions 
and exposure to sewer gas, and ulcers from this cause may 
be either superficial or deep. Xo age is exempt from this 
risk. If children in a house are frequently suffering from 
sore throat, the drainage and the various pipes in the lava- 
tories, baths, and sinks, must be systematically examined. 
If a child is suddenly noticed to have enlarged glands at 
the angle of the jaw in front of the sterno-mastoid, never be 
content without a thorough examination of the tonsils. 
Ulcers in young children are often difficult to see, and 
elude observation in consequence. The chief interest and 
importance of any acute angina in childhood rests upon the 
fact that we have at once to balance the possibilities of its 
origin — to decide, if possible, whether it be simple (that is, 
non-contagious), scarlatinal, or diphtheritic. Now, it is 
easy to say in general terms that the redness of a mere 
angina is bright and that of diphtheria or scarlatina more 
livid; that the membrane of the one is non-adherent and 
yellowish, in the other gray and adherent, leaving a bleed- 
ing surface behind it when detached ; that in one there is 
but little enlargement of glands, in the other much ; in 
diphtheria albuminuria, in angina none; in diphtheria much 



DISEASES OF THE DIGESTIVE TRACT. 107 

constitutional depression, in angina but little. But such 
criteria are not sufficient for practice. Tonsillitis may as- 
sume a severe form, as in the following case, and we are at 
once in doubt whether it is not diphtheritic or scarlatinal. 
A boy aged six was admitted into Guy's Hospital for stone 
in the bladder. A day or two before he was to have been 
operated upon he became feverish, then very ill, and he died 
rapidly. At the inspection both tonsils were found to be 
swollen and boggy from diffuse suppuration. 

On the other hand, diphtheria may be exceedingly mild, 
the membrane but little, the constitutional disturbance actu- 
ally none, and the practitioner flinches from pronouncing 
an opinion, with all that it involves. Thus there are no 
ailments which more require a calm circumspect judgment 
than sore throat and tonsillitis. Every possible evidence 
must be weighed — not only that derived from such observa- 
tions as have been suggested, but also that drawn from the 
general surroundings of the patient. This will involve 
inquiries concerning the child's playmates, its school, the 
house in which it lives, the health of all with whom it in 
any way comes in contact, the health of the neighborhood, 
the drainage, the rain-fall, perhaps even the direction of the 
wind. After this — having exhausted as far as can be the 
sources of evidence — one of three courses is open to us : to 
call the case diphtheritic or scarlatinal, to call it simple 
angina, or to say the nature of the disease is uncertain. It 
is much better to confess to some uncertainty than to make 
light of a complaint which, perhaps, is subsequently proved 
to be of scarlatinal or diphtheritic nature. 

If one distinction may be singled out as less likely to 
mislead us in any disputed case of angina, it is to be elicited 
from the attentive observation of the behavior of the mem- 
branous formation about the tonsils or fauces. No doubt it 
is true for most cases in which membrane forms, that in 



108 THE DISEASES OF CHILDREN. ■ 

simple angina it is non-adherent — is easily detached or ex- 
pressed — and the surface beneath it is intact. In diphtheria 
the membrane is adherent, the surface beneath raw and often 
bleeding, and this even for cases where the constitutional 
symptoms are almost none. 

Chronic Tonsillitis and Hypertrophy of the Tonsils are 
almost sufficiently described by their nomenclature. The 
tonsils are seen to bulge into the fauces, either pushing the 
pillars forwards, or emerging half pedunculated between 
them as pale red bodies, with a trabeculated and pitted sur- 
face, often studded with a yellow secretion which exudes 
from the mouths of the follicles. It is an affection which 
comes on insidiously. When it has made some progress, 
the throat is liable to recurrent attacks of a mild form of 
inflammation or catarrh ; it is but seldom that the increase 
in size dates definitely from an acute attack. There is a 
good old pathological axiom that for one chronic disease 
which follows an acute one, there are many which take an 
opposite course, and this is a good illustration of the rule ; 
at the same time, I do not deny the occasional origin of 
chronic enlargement in repeated attacks of pharyngeal 
catarrh. Nor is this a condition which is certainly stru- 
mous. It is often associated with thick lips and stunted ill- 
formed features, which have something of the ugly type of 
struma in them ; but any decided strumous affections, such 
as glandular abscesses or the like, are rare. Children gener- 
ally " grow out of it," and at fourteen or fifteen years of age 
it ceases to be a disease of any importance. It is, of course, 
sometimes continued on into adult life, and sometimes 
causes trouble in young adults in the same way as in chil- 
dren — viz., by inducing repeated sore throat. It is a par- 
ticularly troublesome affection in those who have a voice 
for singing. It is associated with certain symptoms : 
Firstly, it leads to snoring when the child sleeps — not a 



DISEASES OF THE DIGESTIVE TRACT. IO9 

matter of much concern. Secondly, to deafness, from the 
pressure upon the orifices of the Eustachian tubes, and the 
associated hypertrophic or inflammatory changes which 
take place in the surrounding mucous membrane. This is 
of importance, because such children often appear dull and 
stupid, simply because they are deaf. It interferes too with 
free vocalization, and gives a nasal twang to the voice. It 
causes a frequent cough. Lastly, by partial occlusion of 
the air-passage, the lungs fill badly, and the chest becomes 
distorted ; and, it is said that from the want of full use the 
nostrils contract, the upper jaw fails to develop, and, in con- . 
sequence, the arch of the palate remains high, and the teeth 
become cramped from want of room. The chest becomes 
pigeon-breasted — that is to say, the ribs are flattened in 
laterally, and the sternum and costal cartilages become 
prominent, sometimes quite pointed. This is the natural 
result of interference with the ingress of air into the lungs. 
The respiratory effort continues, but the lungs fail to be 
distended by reason of the obstruction in the throat ; and 
the ribs yield in obedience to the atmospheric pressure 
along their line of least resistance — in other words, in 
those parts of greatest movement — at their junction with 
the costal cartilages backwards to their point of greatest 
curvature. 

Treatment. — No treatment is of much avail but excision, 
and if it should appear that any of the more serious conse- 
quences are in progress, this should be at once advised. 
But it is comparatively seldom that an operation is necessary, 
and fortunately so, for parents manifest great repugnance 
to it. Parrish's food, the syrup of the iodide of iron, and 
cod-liver oil are administered internally ; the child is sent to 
the sea or to some healthy farm in good country air ; the 
recurrence of attacks of angina is kept in check by local 
astringent applications, such as the perchloride of iron with 



I 10 THE DISEASES OF CHILDREN. 

glycerine; the glycerinum acidi tannici, or powdered alum; 
and the hypertrophy gradually subsides, although it cannot 
be said that any one of the remedies prescribed has any 
constant value. External applications to the angle of the 
jaw, turpentine, iodine, iodide of potassium ointment, etc., 
have been much recommended by some ; but I have never 
found them of the slightest benefit. 

[Nitrate of silver, in the stick form, thoroughly applied 
to the surface and burrowed into the enlarged tonsil in 
several places, once or twice a week, is very efficient, and 
gives little pain. When the enlargement occurs in a child 
eight or ten years of age, massage, by the introduction of 
a finger into the mouth, and pressure over the gland ex- 
ternally, for three or four minutes several times a day, also 
acts well. A child can be taught to do this himself. These 
two methods may be combined, and often do good service 
in obstinate cases.] 

Relaxed Throat. — Some children are subject to a relaxed 
throat ; with a little cold or a little malaise, the throat be- 
comes relaxed, as it is termed, and a dry, frequent, tickling 
cough is the consequence. The soft parts are a little flabby, 
perhaps slightly congested. A good old-fashioned formula 
for such cases is a gargle of a glass of port wine, with a 
little cayenne added, or a little perchloride of iron in gly- 
cerine may be used locally, and a tonic internally. 

Hypertrophy of the Pharyngeal Mucous Membrane may 
be mentioned in association with diseases of the tonsils, as 
probably closely allied to the hypertrophy of those bodies, 
and requiring similar treatment. The mucous membrane 
covering the posterior wall of the pharynx, and extending 
upwards to the posterior nares, is thickened and often 
rugose, while it discharges an excess of thick mucus, occa- 
sionally streaked with blood. This condition causes a fre- 
quent cough, sometimes even sickness, from the amount of 



DISEASES OF THE DIGESTIVE TRACT. I I I 

mucus discharged, and it is not so likely to disappear as the 
child grows up. 

Any one of these diseases may originate the disease to 
which the Germans have given the name of pseudo-croup, 
and which appears to be a spasmodic affection of the glottis, 
due to some recurrent catarrh, such as is common in these 
faucial affections. It is described as catarrhal spasm in the 
section devoted to " Diseases of the Respiratory System." 

Retro-pharyngeal Abscess. — The connective tissue be- 
tween the pharynx and the oesophagus and the bodies of the 
vertebrae is prone to suppuration in children, just as that of 
the ischio-rectal region is in adults, and the child is then 
said to have a retro-pharyngeal or retro-cesophageal abscess. 
It is not a common affection ; but many cases have now 
been recorded in a long course of years. Dr. West gives 
sixty-eight cases, collected from various sources, and quite 
recently Bokai has added largely to that number. The data 
derived from them show that the disease is mostly idio- 
pathic, or without obvious cause. Occasionally it follows 
scarlatina, or the suppuration of neighboring glands, and 
occasionally is dependent upon spinal caries. 

It is not confined to any age ; but as a disease of children 
it appears to be more common in infants a few months old. 
No doubt, to this must be attributed the fact that the symp- 
toms are obscure and liable to be overlooked. 

Symptoms. — These somewhat resemble those of large 
tonsils. They are, difficulty in sucking and swallowing — 
perhaps evident pain in swallowing — and snoring respira- 
tion. Sometimes there is pain and rigidity in moving the 
head and neck, and sometimes a diffused swelling of the 
deep parts under the angle of the jaw. The fauces are cov- 
ered with mucus and occupied by a rounded swelling, which 
pushes forward the soft palate, encroaches upon the rima 
glottidis, and to digital examination is elastic and fluctuating. 



112 THE DISEASES OF CHILDREN. 

These signs do not all develop at once ; the maturation of 
the abscess is slow, and apart from fretfulness and want of 
appetite, a certain amount of snuffing — which is attributed 
to cold — may be all that is to be noticed. During the course 
of some days (Henoch speaks often to fourteen or more), a 
swelling forms, and pressure signs supervene ; first of these 
being a more pronounced interference with deglutition. 
Choking fits are easily induced, and fluids return through 
the nose. There may be more or less dyspnoea. 

I have once or twice seen a diffuse suppurative cellulitis 
in this region without any tendency to localization or point- 
ing. Probably no well-defined distinction could be made 
between the two classes of cases ; but the fever may be ex- 
pected to be more severe, the swelling in the neck more 
diffused, and the outlook is decidedly more gloomy in the 
diffiuse than in the localized form. 

Prognosis. — If the abscess be opened, the pus evacuated 
safely, and there be no persistent cause in the way of caries 
of the spine, the child may do well ; but so long as the ab- 
scess remains unopened, it may mature and open spontane- 
ously, and the pus be sucked into the lungs during inspira- 
tion, and death from suffocation result. 

Treatment. — The abscess should be opened as soon as 
possible, both to prevent any large increase in size, and to 
avert spontaneous rupture at inconvenient times. The in- 
cision should be vertical, with guarded bistoury, all but 
the point being encased in strapping. 

Cynanche Parotidea. — Mumps will be described under 
the head of u Contagious Diseases." There is, however, 
another form of disease — viz., that which complicates or 
succeeds to scarlatina, measles, typhoid fever, diphtheria, 
etc. It has been supposed, and probably correctly, that this 
form is of septic origin. At any rate, it commonly termi- 
nates in suppuration, and it is this that must be watched, 



DISEASES OF THE DIGESTIVE TRACT. II3 

for the abscess will often open into the external auditory 
passage. Pus should be evacuated by an incision as soon 
as it is detected. This disease has sometimes led to para- 
lysis of the facial nerve, and it is a serious complication of 
any of the exanthemata or continued fevers, often forebod- 
ing a fatal issue. 

The oesophagus is a part of the alimentary tract which 
may be said to have no pathology, it is so rarely diseased, 
and when it is, a diagnosis is but seldom possible. In a 
work of this kind, therefore, it will be sufficient to mention 
that thrush or diphtheritic membrane may extend along the 
tube; and that, in rare cases, an acute inflammation is found 
upon the post-mortem table, indicated by thickening of the 
walls, increased rugosity of the lining membrane, changes 
of color of the surface from the usual pale opaque white to 
pinkish or even black, and more or less unevenness of sur- 
face from loss of substance. These appearances must not be 
mistaken for those of cadaveric origin, which are confined 
entirely to the epithelial surface or to staining of the various 
tissues. Acute inflammation may of course be met with as 
a result of swallowing boiling water; and from the same 
cause, stricture of the tube is occasionally found in children 
of three or four years old. Lastly, let me mention that con- 
genital malformations are met with now and then. The 
oesophagus may end in some part of its course in a culde sac ; 
it has been known to terminate in the trachea instead of the 
stomach ; and there are some reasons for thinking that 
stricture of its cardiac end, a disease of adult life, may in rare 
cases be congenital. Some of these conditions admit of no 
treatment, and are necessarily fatal ; some admit only of 
surgical treatment ; and of those which are medical — thrush, 
diphtheria, and the like — the rules laid down in other parts 
of the book will supply all the information that is needed. 



114 THE DISEASES QF CHILDREN. 



CHAPTER VII. 

DISEASES OF THE DIGESTIVE TRACT {continued). 

Some of the diseases of the stomach are closely allied to 
those of the intestines already described. Acute or milk 
dyspepsia, gastralgia, and vomiting are so ; all these being 
symptomatic or functional diseases. They have no morbid 
anatomy, and for this reason they are of somewhat uncer- 
tain nature. Herein lies a puzzle to the student, because 
the symptoms which to one writer indicate — let us say, for 
example, acute dyspepsia, to another suggest gastric fever, 
to another perhaps dentition fever. Gastralgia may in like 
manner be, for all we can say positively to the contrary, a 
colic, or a nerve storm in some other part of the abdomen, 
just as well as an actual affection of the stomach itself. 

I shall therefore as far as possible avoid the use of terms 
the correctness of which we are not sure of, and describe 
as cases such sets of symptoms as are common in childhood, 
and which are attributed, both popularly and professionally, 
to gastric disorder. 

And first of all, let us take a case of fever : gastric fever 
if you will, but that the gastric origin is uncertain ; acute 
dyspepsia if you will, but even true dyspepsia is doubtful. 

A healthy child of twelve months, with its two lower in- 
cisors cut, ailed for a day or two with feverishness, consti- 
pation, and occasional vomiting. When seen first, it was 
fretful, with a temperature of 100.4 , an d a quick pulse and 
full abdomen. The temperature went up to 103 , remained 
up for two days and a half, and then fell rapidly to normal ; 
the tongue was thickly furred, the bowels confined, the mo- 



DISEASES OF THE DIGESTIVE TRACT. I 1 5 

tions light in color, and there was occasional vomiting 
The bowels were opened freely by rhubarb and soda, and 
acetate of ammonium was given internally. A week later 
one of the upper incisors was cut. 

Such cases as this are very common. They occur during 
the progress of dentition, but have often no definite relation 
to the eruption of a tooth. They occur, moreover, at the 
time of weaning, before the stomach has become accustomed 
to the change in its dietary. They occur notably sometimes 
after errors in feeding. They will sometimes speedily re- 
lieve themselves by vomiting, so that there is some reason 
at any rate for considering them of gastric origin. They 
are somewhat erratic in course and duration. Sometimes 
the temperature will run up quite suddenly at night, and 
come down again, and remain normal, after the following 
morning, apparently in obedience to a febrifuge, but quite 
as likely in dependence upon what may be called the initial 
vitality of the fever. Sometimes the pyrexia is more pro- 
longed, and we perhaps begin to discuss the question of 
enteric fever. In such cases, the idea suggested by the term 
infective gastritis may contain a germ of truth, and at any 
rate, in dealing with an affection of the nature of which we 
are quite in the dark, some fugacious erythema of the 
gastro-intestinal tract may be suggested as a possible cause 
of the elevated temperature. 

In older children something of the same kind happens, 
the fever being associated with an acute bronchitis of the 
larger tubes. 

Emily W. has been a frequent attendant, between the ages 
of two and a half years and six years, with attacks which 
come on quite suddenly, with vomiting, confined bowels, 
delirium, and high fever. In one of these attacks her face 
was flushed, temp. 103 , pulse 160; the tongue thickly fur- 
red with white fur, and red papillae showing through ; the 



Il6 THE DISEASES OF CHILDREN. 

respiration rapid, harsh all over, with copious dry rales, but 
no other physical signs. These symptoms are always re- 
lieved by a dose of castor-oil, and in two or three days she 
is quite well again. 

In another class of cases, fever and cough are combined 
with vomiting and purging. A boy of three years was 
brought for fever and cough, which had come on quite 
suddenly, and after which the bowels were loose, and he 
was frequently sick, the attack extending over a fortnight. 
A little rhonchus was audible in various parts of his chest, 
but no other physical sign, and he rapidly improved by 
careful dieting and a simple citrate of potassium mixture. 

The treatment in all these cases is dietetic and aperient. 
In the case of infants, 5j of castor-oil may be given at once, 
and, if the child be of sufficient age, I must confess to a 
liking for small doses of calomel and Dover's powder, a 
sixth of a grain of each every two hours, for three or four 
doses, following the aperient. It may be difficult to explain 
the action of these drugs, but the fever seems to subside 
more rapidly with them than without them. Another good 
mixture is a combination of the tr. camph. co.,* acetate 
of ammonium and citrate of potassium (F. 29). Another, 
salicylate of sodium with liq. ammonii acetatis (F. 2). 

In the gastric fevers of older children a couple of grains 
of jalapin with two of calomel, or a piece of Tamar Indien, 
form good and easily disguised aperients. They should be 
followed by such gentle laxatives and alteratives as fluid 
magnesia 5ij, or 5j of confection of sulpherf three times a 
day; or rhubarb and soda (F. 11). 

* Tr. Camph. Comp. Br. P. is si miliar to Tr. Opii Camph. U. S. P. — Ed. 

j- Confectio Sulphuris, Br. P., contains: 

Sublimed sulphur, . . . . . .4 ounces 

Acid tartrate of potassium, in powder, . . 1 ounce 

Syrup of orange-peel, 4 fl. ounces. — Ed. 



DISEASES OF THE DIGESTIVE TRACT. II7 

A tonic is usually necessary afterwards, and none is better 
than Easton's syrupus ferri et quiniae et strychniae phospha- 
tum : half a teaspoonful in water three times a day. 

Abdominal Neuroses. — Another large group of so-called 
stomach cases exhibit more chronic symptoms. The fever 
is absent or very slight, but the tongue is furred, the breath 
foul, the appetite capricious, the bowels irregular, and super- 
added is a frequent dry hollow cough, which is often called 
a " stomach cough." The condition upon which these 
symptoms depend is a very indefinite one, if we attempt to 
treat of it pathologically, but distinct enough as a clinical 
fact. We have a dull, languid state, with opaque and greasy 
skin, pallor and wasting. The tongue is flabby, moist, and 
covered with a whitish fur ; the appetite is capricious — some- 
times ravenous, sometimes dainty, sometimes replaced by 
an inordinate thirst. There is a liability to severe stomach- 
ache, which in some children attacks them when they wake 
in the morning, in others appears to be excited by the in- 
gestion of food. The bowels are perhaps confined and re- 
laxed alternately for days together. The constipation may 
attract but little attention, but the diarrhoea, particularly if 
combined with vomiting, makes the parents anxious. The 
child is said to be subject to bilious attacks ; or a dry, hol- 
low, frequent cough frightens every one around into the 
idea of consumption. Nor should this cough be passed 
over without alluding to the close sympathy that exists be- 
tween the stomach and the lungs. The diseases of the one 
organ are so frequently reflected in perverted functions of 
the other, that it is quite worth while bearing the fact 
in mind. It must not be supposed that all these symp- 
toms are to be found in any one case. Some children will 
require treatment for griping abdominal pain of a parox- 
ysmal kind, others for bilious attacks, others for pain in the 
side, others for cough, yet others perhaps for nightmare ; 



Il8 THE DISEASES OF CHILDREN. 

but when we come to investigate cases, certain other features 
are found in common — viz., pallor, wasting, furred tongue, 
foul breath, irregular bowels, etc. Now these are all symp- 
toms which might be due to a great variety of causes, 
and they are not associated with any known anatomical 
lesions. Nevertheless, as a group they have much con- 
stancy, and it becomes necessary to assign them a place, and 
for purposes of recognition, a name also, amongst gastro- 
intestinal disorders. Dr. Eustace Smith, in his " Wasting 
Diseases," proposes the name " Mucous Disease." He con- 
siders a soft, flabby, indented tongue, smeared over with a 
gum-like mucus, to be particularly characteristic; and the 
side-pain, stomach-ache, etc., to be due to accumulations of 
mucus in the bowel, and its evacuation to be the cause of the 
periodical diarrhoeas. As an accurate picture of the affec- 
tion we are now engaged upon, the student cannot do better 
than read the chapter referred to in Dr. Eustace Smith's book.* 
But I should hesitate to indorse the term " Mucous Disease," 
first because I have not been able to satisfy myself of the 
discharge of any such large quantities of mucus from the 
bowel in such cases; secondly, because it is by no means 
certain that mucus, even if it should collect, would give rise 
to such symptoms; thirdly, were it to do so, it would still 
have to own some cause behind it. But no doubt these 
chronic gastro- intestinal derangements are a part of the 
series which are so described. 

For my own part, I am persuaded that although they may 
seem to be caused by temporary conditions, such as errors 
in diet, these varied pains and aches are often but the ex- 
pression of a constitutional build. They are an evidence of 
nervous instability, and they are found in nervous children 
or nervous families. By this I mean that children subject 

* "Wasting Diseases," 3d edition, p. 199. 



DISEASES OF THE DIGESTIVE TRACT. I 19 

to these ailments are the offspring of those whose nervous 
systems are feeble or diseased , of those who have suffered 
from, or who are closely related to, the subjects of fits, insan- 
ity, hysteria, neuralgia, rheumatism, or gout; or if not, have 
in themselves given other evidence of unstable nerves in 
the convulsions of infancy, passionateness, morbid timidity, 
chorea or rheumatism. Such children have nightmare 
badly, somnambulism, nocturnal incontinence of urine. 
Their moral nature is essentially angular. They are an odd 
lot. The gastro-intestinal disturbances that are met with 
have much in them to suggest a nervous origin. The in- 
significance of the exciting causes, the suddenness of the 
attack, the suddenness of its subsidence, the nature of the 
attack in many cases, even the presence of an excess of 
mucus, if that be a dominant symptom, each and all of these 
symptoms are compatible with enfeebled nerve control. 

[The editor favors Dr. Eustace Smith's view. The course 
of the affection is usually chronic, and during it, there are 
apt to be periodical attacks of vomiting and diarrhoea. 
Frequently dark circles appear about the eyes, which at 
times look almost as though painted with India ink. The 
face is subject to rapid changes of color, sometimes it is 
" deadly " pale, as if syncope w r as imminent, at others the 
cheeks wear a circumscribed flush. The child is languid by 
day, restless by night, and sleep is disturbed by night terrors, 
his appetite is capricious, his abdomen large and protruding, 
presenting a marked contrast to his wasted limbs and body. 
The stools are scanty, infrequent, composed of small dry 
lumps of faeces, and contain a quantity of mucus, in 
which it is not unusual to find a number of thread-worms. 
The periodical attacks, lasting one or two days, seem to be 
due to accumulation of mucus and partial retention of faeces ; 
during them large quantities of both of these substances be- 
ing voided*, there is a temporary improvement in the general 



120 THE DISEASES OF CHILDREN. 

symptoms. They are, therefore, to a certain extent, critical 
discharges. 

The symptoms of chronic indigestion are similar in nature, 
though less severe than those of mucous disease. In both 
conditions there is a catarrh of the gastro-intestinal mucous 
membrane, but that of mucous disease is by far the more 
intense.] 

Diagnosis. — The abdominal pains which so often form 
the striking feature of the complaint are very similar to those 
present in many cases of early tuberculosis, or tabes mesen- 
terica, and these diseases are not always easy to distinguish. 
Mesenteric disease should be characterized by a greater 
fulness of abdomen, more persistent pain, less constipation, 
more wasting. On the other hand, tabes, in its earlier 
stages, is very liable to be overlooked if abdominal neuroses, 
with their fascinating capacity for fitting all measures, are 
allowed to usurp an undue proportion of the observer's 
imaginative faculties. 

[It is of great importance to make an early diagnosis be- 
tween mucous disease and tuberculosis. In the former, the 
tongue is slimy and swollen, the bowels are constipated, the 
stools composed in great part of mucus, the skin sallow, 
dry, and rough, with exfoliating epidermis, and there is no 
pyrexia. Features distinct from those of tuberculosis. 
Should, however, fever occur in a case presenting the symp- 
toms of mucous disease, an event quite possible in the 
paroxysms of vomiting and purging, or during the course 
of some intercurrent disorder, it is necessary to make a 
careful examination of the lungs, and take the temperature 
for several days, to be sure of the diagnosis.] 

Treatment. — On general principles these children require 
most careful feeding — not only must the material be super- 
vised, but also the amount taken and the way in which it is 
taken. They are to have plenty of milk and bread, sugar 



DISEASES OF THE DIGESTIVE TRACT. 121 

and butter in moderation, meat and fish ; but vegetables in 
small quantity. Potato may be given if it is carefully pureed 
with milk, so as to be almost fluid, but not otherwise. 
Bolted potato is very trying to a child's stomach. Next they 
require tonics, of which bicarbonate of potassium and tartrate 
of iron aa gr. v. with syrup and water, is very generally suit- 
able (F. 30). 

[In the treatment of mucous disease it is of the greatest 
consequence to regulate the diet. The child must be fed, 
so far as possible, on milk, meat, and eggs. As farinaceous 
food readily undergoes fermentation, and by the acids so 
generated, increases the catarrh, all articles of this class 
should be rigidly excluded except bread, and this must be 
eaten stale or toasted. After the child has reached the age 
of three years, a most satisfactory diet is such as this : 

Breakfast — milk with lime-water (in the proportion of 
f^ss-ij to Oss), a soft-boiled egg y and stale bread or toast. 
Time of meal, 7 to 8 o'clock, a.m. 

Dinner — roasted or broiled lean meat, occasionally a bowl 
of meat broth, and stale bread. Time of meal, midday. 

Supper — milk with lime-water and stale bread or toast. 
Time of meal, 6 to 7 o'clock, p.m. 

The quantity eaten at each meal should be moderate, and 
if the child become hungry in the intervals, a cup of milk 
and a small slice of bread may be given. When improve- 
ment begins, the diet may gradually be increased ; boiled 
potatoes, salted meats, molasses and pastry being among the 
last articles to be allowed.] 

But the special symptoms require special treatment. The 
abdominal pains which are so common, are almost invariably 
relieved by small doses of Dover's powder. They are not 
common in children under three or four years of age, so 
that two or three grains of the powder may be given twice 
or three times a day in most_ cases, and in older children 



122 THE DISEASES OF CHILDREN. 

four or five grains may be necessary ; and this treatment 
should be continued for at least ten days or a fortnight. 

For the various other pains and aches, bromide of potas- 
sium or ammonium is most generally suitable, and it may 
sometimes be advantageously combined with half-drachm 
doses of the syrup of chloral.* 

[In mucous disease, should the loss of digestive power be 
in excess of the mucous flux, great advantage is derived 
from the combination of dilute muriatic acid, with one of 
the cinchona alkaloids, or with nux vomica. But if the 
opposite condition prevails, and mucus is vomited, or appears 
in the stools, alkalies are much more efficient than acids, 
as they have a tendency to arrest the formation of mucus, 
and at the same time, by neutralizing the acids formed by 
fermentation, to remove one source of irritation. The best 
alkali is the bicarbonate of sodium, administered in combi- 
nation with compound infusion of gentian or infusion of 
columbo, either bitter aiding the action of the alkali by its 
power of checking fermentation. Often after improving for 
a time under this treatment, a case comes to a stand-still ; 
when this happens, the favorable progress may be re-estab- 
lished by the substitution of dilute muriatic acid for the 
alkali. Iron in the following combination is often very 
useful : 

R. Ferri Sulph. Exsiccat., . . . gr. iv. 

Tr. Aloes et Myrrhae, . . . . f !J iv. 
Syr. Rhei Aromat., . . . . q. s. ad f ^iij. M. 

A teaspoonful to be taken three times a day, for a child of three or four years. 

Both the iron and rhubarb tend to check the formation of 
mucus, the aloes and the rhubarb clear the bowels of mucus • 

* Syrupus Chloral. Br. P. contains ten grains of hydrate of chloral to a 
fluid-drachm of equal parts of simple syrup and distilled water. — Ed. 



DISEASES OF THE DIGESTIVE TRACT. 1 23 

and undigested food, while the myrrh is a direct tonic to the 
relaxed mucous membrane.] 

In the bronchitis of the larger tubes, a little tr. camph. co. 
forms a useful adjunct to the aperient medicine, and perhaps 
hastens the return to a normal state ; and in all cases the 
bowels must be kept open by some mild aperient, than 
which none can be better than the compound decoction of 
aloes, or ten-minim doses of tincture of podophyllin. A 
little Friedrichshall water taken in the morning is another 
purgative which some children take well. Later on, strychnia 
may be combined with the iron, either as the liquor, the 
tr. nucis vomicae, or as Fellows' or Easton's syrup. 

There yet remain one or two points to be noticed upon 
the character of the evacuations from the bowels. I need 
not repeat here what has been said under the head of 
" Chronic Diarrhoea." Nor need more than a mention be 
made of the common anxiety which is expressed by so 
many mothers at the black color of the motions when chil- 
dren are taking iron salts. Iron is so common a remedy 
for all sorts of ailments in childhood, that every student is 
familiar with the inky appearance of the motion produced 
by it. But the passage of blood is sufficiently common to 
require special notice, and various undigested or partly di- 
gested substances produce peculiar appearances which may 
well receive special attention. 

Blood may be passed unaltered, or resembling treacle or 
pitch (melsena). Fresh blood is a common constituent, and 
it comes from the lower part of the bowel, in association 
with the irritation set up by ascarides, with prolapse of the 
rectum, or with polypus. Occasionally it may be passed in 
quantity, and even in clots, when the child has been fed upon 
indigestible food. The following case is an example of 
this: 

A child, aged seventeen months, had been fed upon meat 



124 THE DISEASES OF CHILDREN. 

and potatoes and arrowroot. Five days before she was 
brought to the hospital she began to pass blood, and after- 
wards some came away at every action of the bowels, some- 
times in clots. Some straining occurred with each action, 
and she turned very pale. Nothing abnormal was to be felt 
in the abdomen, nor was there any polypus or other cause 
for the bleeding to be felt per anum ; and it was therefore 
concluded that the diet was at fault. Careful feeding was 
ordered, and a mixture containing bicarbonate of potassium, 
fluid magnesia, and tr. of rhubarb and cinnamon water; and 
the bleeding ceased. 

It also occasionally happens that a small ulcer in the 
colon or elsewhere in typhoid fever, or in children who are 
otherwise ill, comes across the line of a small artery, and 
leads to hemorrhage ; but the pre-existing indications of 
disease would be, in such a case, sufficient to render a diag- 
nosis possible, the hemorrhage would have nothing in it to 
take it out of the category of a similiar bleeding in adults 
under like circumstances, and the treatment would follow 
the same lines. 

Ascarides and prolapsus ani have already been consid- 
ered. 

Rectal polypus is not rare. It causes persistent and 
occasionally severe hemorrhage from the bowels, and 
sometimes children are completely blanched by it. The 
polypi are usually solitary, pedunculated and projecting 
from the mucous membrane some short distance above the 
internal sphincter. They are firm fleshy bodies, composed of 
villous processes and crypts covered and lined by columnar 
epithelium, and in section they form beautiful microscopic 
objects. Although these polypi are nearly always solitary, 
I have known the whole of the rectal mucous membrane to 
be covered by them. 

Treatment. — The forefinger, well oiled, should be passed 



DISEASES OF THE DIGESTIVE TRACT. 1 25 

into the rectum, the polypus hooked down, and its pedicle 
frayed through with the nail. Polypi are, for the most part, 
easily detached. Should there be any difficulty in remov- 
ing them in this way, they must be ligatured ; but this is 
seldom necessary. 

Melsena neonatorum is a not very infrequent occurrence, 
and there has been considerable discussion as to the source 
of the blood. In the only case that I have seen, a small 
oval ulcer had opened into an artery at the cardiac end of 
the greater curvature of the stomach. But this is perhaps 
an exceptional condition ; at any rate, the majority of cases 
have been supposed to be due to venous congestion ; a 
minority only have been proved to be due to ulcer. In 
typical cases, within a few hours of birth the infant either 
vomits blood or passes a quantity per anum, and sinks 
within a short period. The case alluded to occurred in the 
practice of my friend, Mr. W. Cock. The child was born 
naturally, and was to all appearance healthy. About 
twenty-four hours after birth it began to pass black blood 
per anum, and vomited blood from the mouth, and it sank 
six hours afterwards. It is a very serious affection, and in 
most cases fatal. Indeed, it hardly gives an opportunity for 
treatment; but should it do so, some cold alum whey (F. 
36) should be gwen, and some castor-oil, which by acting 
upon the bowels may do something to relieve any local 
plethora which might exist. Dr. West narrates two cases 
of melsena in somewhat older children, in which the bleed- 
ing was perhaps due to some impoverished state of blood ; 
and it may be added that no one is exempt from ulcer 
of the stomach, though it is far less common in infancy 
and childhood than in later years. 

Oily matter is occasionally passed in quantity from the 
bowels ; the evacuations being, at the same time, very offen- 
sive. This condition is probably due to defective action of 



126 THE DISEASES OF CHILDREN. 

the liver, pancreas, and intestinal glands, under which the 
fatty matters of the food are not properly emulsified, and, 
therefore, not absorbed. There is no experience at hand 
sufficiently large to warrant one in saying what is the best 
medicinal treatment for such cases ; but the symptom has 
disappeared under restricted diet, the use of sulphate of 
magnesium, sulphate of iron, and bicarbonate of sodium. 

When, from any cause, it is necessary to feed children 
upon unusually large quantities of milk, the motions some- 
times contain a yellowish and greenish thick fluid, not at all 
unlike thick pus, due to partially digested milk. In a case 
of empyema, it was so like pus that it led to the supposition 
that the pleuritic abscess had opened into the colon through 
the diaphragm. But there was no other reason to suppose 
that this was so, and microscopic examination showed the 
material to be fatty. 

The indication probably is that the absorption limit has 
been overstepped and that waste is going on. The milk 
should, therefore, be lessened in quantity. 

Vomiting in children is almost invariably functional. It 
is supposed to be due, it is true, to gastric catarrh, and, 
more or less, catarrh is not improbably present ; but we 
know nothing of this as a demonstrated condition, and it is 
therefore necessary in many cases to treat .the symptom as 
the disease. Vomiting is an important affection chiefly 
when it occurs in nurselings and is chronic. For this 
reason it is advisable to treat of it according to the age of 
the patient, and to supplement an arrangement of this kind 
by adding a third group of cases in which vomiting is a re- 
flex symptom of disease elsewhere. Thus we shall have : 

(i) The vomiting of nurselings. 

(2) The vomiting of older children. 

(3) Reflex vomiting. 



DISEASES OF THE DIGESTIVE TRACT. \2J 

(i) Infants from the first day of their birth are subject to 
vomiting, not from disease, but from a perfectly physiologi- 
cal safety-valve action on the part of the stomach. It is 
impossible to adjust the ingress of food so nicely to the 
needs of the organ that just the proper quantity, and no 
more, is taken, and should there be any surplus, it is re- 
jected. Many infants " posset " quite regularly, more or 
less, for the first few months of life ; sometimes very soon 
after taking food, when gas is eructated with it ; at others, 
later, during the progress of digestion. And as in the mus- 
cular play of an infant's limbs we can see the physiological 
side of what in morbid excess becomes convulsion, so here 
we have a physiological action, which, if uncontrolled, may 
run riot in chronic vomiting. 

As I have had occasion to say before, in dealing with like 
disorders of the intestines, in all neuro-muscular apparatus 
♦such as this, it is not so much change of structure as bad 
habit we have to combat ; an abnormally sensitive nervous 
circuit must be broken, or in some way or other rendered 
less automatic in its action. 

All vomiting in infants must be watched. So long as it 
comes on early after taking food ; while the quantity re- 
jected forms but a small proportion of that taken ; and the 
child does not suffer in any way in health ; no anxiety need 
be felt at its continuance. Should it become increasingly 
frequent, or seem in any way to be in excess, it must be 
taken in hand, and it is generally quite amenable to treat- 
ment. If, on the other hand, it be neglected, it recurs at 
intervals which tend to become shorter and shorter. The 
vomit each time becomes more copious, till, finally, no food 
is retained, the vomited matters lose the well-known char- 
acters of semi-digested food, and a thin watery, sour-smell- 
ing liquid is discharged instead. The child meanwhile 
gradually changes. Plump and healthy, perhaps, at the 



128 THE DISEASES OF CHILDREN. 

outset, it loses its color, and its limbs become soft and 
flabby; it cries after taking its food; its stomach is dis- 
tended with gas, and painful on pressure, and the bowels 
become confined. The blood fails to be replenished owing 
to the persistence of the vomiting, and little by little the 
child becomes a juiceless, withered, wasted thing, with dry, 
often scurfy, skin, depressed fontanelle, and pinched pegtop 
face. The surface is cool, the extremities cold ; it is feeble, 
constantly whining, voracious in its thirst ; its mouth and 
tongue red and dry, with thrush dotted about in various 
parts ; and thus it dies starved. The immediate precursor 
and cause of death may be bronchitis and pneumonia, or 
occasionally some thrombosis of the cerebral sinuses from 
thickening of the blood, and slowing of the cranial circula- 
tion, with its semi-comatose condition, or convulsions ; but 
these are the necessary results of the enfeebled condition 
brought about by the prolonged starvation. 

An examination of the bodies of such infants shows no 
disease. There may be an excess of mucus in the stomach, 
some pallor, or even some redness or ecchymosis of the 
mucous membrane ; but these things mean very little, and, 
like the brain of an epileptic, it is but exceptionally that the 
stomach of a child that dies of chronic vomiting shows any 
sign. Thus there is no difference in the result, and but little 
difference between the symptoms, of this disease and chronic 
diarrhoea. The description of the one might well read for 
that of the other. 

Vomiting as an acute symptom in infants is of different 
significance. The chronic disease we have just described 
is unassociated with fever; but vomiting may be associated 
with fever and furred tongue, and with either constipation 
or diarrhoea ; in such case it may mean that the child's food 
'has disagreed with it ; or that some exanthem, particularly 
scarlatina, is about to show itself; or that some brain mis- 



DISEASES OF THE DIGESTIVE TRACT. 



129 



chief is brewing ; or, perhaps, that some intestinal mischief, 
intussusception, for example, has come on. 

These various possibilities must be considered and some 
conclusion arrived at, and this will not often be a matter of 
difficulty when we have mastered the differential features of 
the diseases of which vomiting is a sign. This can only 
be done under each disease as it comes before us, but .it 
may be said in short — that the vomiting of indigestion is 
associated with a quick regular pulse and a full stomach, 
and that it is very common ; if diarrhoea be present also, 
the diagnosis is nearly certain. The vomiting w T hich ushers 
in an exanthem is not a common thing in infants, but an 
examination of the throat and glands might help us to its 
elimination. The vomiting of brain disease is associated 
with an Irregular pulse, constipation, and retraction of the 
abdomen ; whilst for intussusception the pale collapsed ap- 
pearance is, perhaps, the best early hint. 

Treatment. — To take acute vomiting first, which from 
previous investigation is ascertained to be due to undigested 
food. If the spontaneous action of the stomach has not 
already done all that be needed, an emetic of ipecacuanha 
wine (a teaspoonful), or five grains of the powdered ipecacu- 
anha root, should be given, and subsequently a dose of castor- 
oil, or a grain of calomel and a grain of rhubarb. 

A little bicarbonate of sodium and citrate of potassium 
may be given afterwards three or four times a day ; the diet 
being restricted. Most of the children in whom vomiting 
occurs have been fed artificially, but in any case it is needful 
to reduce temporarily the quantity of food given. If the 
breast be the medium, then the child must be nursed less 
frequently, and the quantity taken at each meal should be 
diminished. If other food be given, it is to be diluted and 
the quantity strictly regulated in the same way. Probably 



I3O THE DISEASES OF CHILDREN. 

nothing more will be necessary, and the attack will speedily 
subside. 

[The following very simple combination is often most 
successful in checking acute vomiting : 

R. Aquae Cinnamomi, 

Liquor Calcis, aafgj. M. 

One teaspoonful p. r. n. for a child of ten months or more.] 

Chronic Vomiting, on the other hand, will yield to noth- 
ing else than patience. Like chronic diarrhoea it is a most 
troublesome habit to eradicate and often keeps the upper 
hand of all treatment. Yet in no class of cases are the re- 
sults of perseverance more perceptible or more satisfactory. 
I have nothing to add upon the question of diet to what has 
already been said in previous chapters. The one common 
error in treatment is, want of patience. A child is sick, and 
the food is judged, and possibly correctly, to be unsuited for 
it. The food is changed, but with no better result — some- 
thing else is tried, but still the sickness continues; and soon, 
with anything and everything that kind friends suggest, the 
anxious mother has run from food to food, and thereby 
exhausted in the process her wits, her energy, and her child. 

The first thing to attend to is that there be a strong sen- 
sible nurse upon whom one can rely. There are few more 
discomforting or wearying things than a fretful, ailing infant; 
and it is of very little use to undertake the treatment of such 
a case as chronic vomiting or diarrhoea, with a nurse who 
is worn-out and disheartened. It will next be advisable, in 
all probability, to make a clean sweep of all foods, and to 
start afresh on one of the simplest — we will say artificial 
human milk, for example. Whatever may be selected will 
be met with the objection that it has been tried and has failed. 
But never mind, let it be tried again under the strictest limi- 
tations and directions from the medical attendant, and let it 



DISEASES OF THE DIGESTIVE TRACT. 131 

not be discarded until he has satisfied himself that it is use- 
less. Nor should he be satisfied of this until some approxi- 
mate idea has been obtained of the amount that the vomit 
bears to the food taken. The sickness is seldom arrested 
suddenly by any treatment, so that if the quantity returned 
lessens, the food selected may be doing its work. Having 
chosen our food — be it artificial human milk, or milk and 
lime-water, milk and barley-water, whey and cream, or cream 
alone, veal broth, etc. — the next thing is to attend to the 
quantity given and to the method of its administration. In 
the worst cases all bottles must be abjured, and the child 
fed by the spoon only. It may be that the stomach will 
tolerate no more than a teaspoonful at a time — never mind, 
as has been before remarked, a teaspoonful retained is worth 
more than a tablespoonful vomited — and a good deal of 
nourishment can be administered by teaspoonfuls given at 
frequent intervals. Whatever food is given should be cold. 
The body at the same time is to be kept as warm' as possible 
and the child free from the effluvia of its own discharges. 

In medicine nothing is better than calomel in doses of a 
sixth of a grain put upon the tongue every three or four 
hours ; hydrocyanic acid and bicarbonate of sodium are use- 
ful, given in combination, or the former may be given, as in 
(F. 32); ipecacuanha in drop doses is recommended by 
some; arsenic with nux vomica and bicarbonate of sodium 
by others. But careful dieting is, decidedly, of more impor- 
tance than any medicine, and upon it must our main reliance 
be based. It frequently happens, in the worst cases, that 
stimulants are necessary, five drops of brandy or rectified 
spirit being given every hour as occasion demands. 

[Arsenic in minute doses, for instance half a drop of Fow- 
ler's Solution (Liq. Potassii Arsenitis), in a teaspoonful of 
water three times a day for infants, often produces most 
gratifying results.] 



132 THE DISEASES OF CHILDREN. 

(2) The vomiting of children past the age of immediate 
infancy is most commonly due to indigestion ; occasionally 
in girls it is the precocious development of symptoms well 
known in young adult females as the outcome of hysteria. 
Sudden causeless vomiting in a child of previously good 
health should suggest the possibility of the onset of some 
acute disease, particularly of scarlatina ; and, as at any other 
time of life, vomiting may be due to disease elsewhere. 

The functional vomiting, of which alone I need speak, 
after what has just been said, is to be diagnosed, as it would 
be in adult life, by its frequency, its quick onset after food, 
the absence of symptoms of any definite illness, and by the 
nervous aspect of the patient. Children affected by it are 
usually from nine or ten to fourteen years. 

(3) Reflex vomiting may be due to meningitis or tumor 
of the brain, to chronic disease of the lungs, to pertussis, to 
dentition, or to worms. The vomiting of brain disease 
is erratic in its occurrence — the tongue is clean, and there is 
an absence of all gastro-intestinal symptoms; there is other 
evidence of cerebral disease, such as headache, or impaired 
muscular power, diminished acuteness of vision, and inter- 
mittent action of the pulse. In disease of the lung, there is 
the cough and emaciation; in pertussis, the paroxysmal 
cough and bloated aspect generally suffice for a diagnosis, 
but it occasionally happens that the sickness is the only ail- 
ment of which complaint is made, the cough being forgotten. 
Dentition and worms have already been mentioned. 

Under the head of treatment, I need only say, that one is 
often driven to treat symptoms, and happily with a success 
by no means inconsiderable. 

Ulcer of the Stomach is not very uncommon in newborn 
infants, but is decidedly rare afterwards. It occurs either 
as a single minute round ulcer, with a perforating tendency 
as in adults, or as numerous small scattered erosions which 



DISEASES OF THE DIGESTIVE TRACT. 1 33 

stud the surface of the mucous membrane and assume the 
appearance of ulcerated follicles. The perforating ulcer 
has been ascribed to all the various causes which are held 
to be potent in producing the gastric ulcer of adult life, and 
it is probable that for children after they are weaned the 
pathology of the two may be the same ; but for newborn 
infants, the circulatory disturbances which ensue somewhat 
suddenly at birth, the sudden arrest of the placental stream, 
the gradual development of the pulmonary circulation, asso- 
ciated as it often is with partial atelectasis, so patently pre- 
dispose to venous stagnation in the abdominal viscera as to 
give much ground for the belief that congestion and even 
ecchymosis are at the root of the ulceration. The scattered 
ulceration has been found under such varied clinical condi- 
tions that it is impossible to attach any definite meaning to 
it, although one may suppose with reason that it is the re- 
sult of some chronic catarrh. 

Symptoms. — Vomiting of blood and melaena are the only 
indications which point to the existence of an ulcer of the 
stomach, in the infant. A healthy child within a few hours 
of its birth who begins to vomit blood and to pass pitchy 
matter per anum, may have a gastric ulcer. More than this 
we cannot say, for the same symptoms may certainly be 
present without any ulcer. In the few cases in which a 
gastric ulcer is present in older children, the symptoms, if 
definite, should be as in adults — epigastric pain and vomit- 
ing. The follicular ulcer cannot be diagnosed, and has 
always been found accidentally upon the post-mortem 
table. 

Treatment. — The bleeding is often so quickly fatal that 
nothing is available; but the directions already given for 
cases of melaena neonatorum will equally apply here. 

Tubercular Ulceration of the stomach is occasionally 






134 THE DISEASES OF CHILDREN. 

met with, but it has no symptoms apart from those of tabes 
mesenterica. 

Softening of the Stomach or gastro-malacia is a condi- 
tion which has received a great deal of attention, and some 
of the most distinguished writers upon the diseases of chil- 
dren have credited it with being a distinct disease, but to 
my mind with insufficient reason. Of symptoms it has 
none which are in any way characteristic, and the appear- 
ances found after death are identical with those of post- 
mortem solution. Whether this as well as other changes 
which are cadaveric in their nature may not at times com- 
mence during the last hours of life may perhaps be an open 
question, but that the change is, in all cases, essentially 
what has been described as post-mortem solution there is 
no doubt. I may give a fact which bears upon this point. 
I have twice found evidence of a gastric solution of the 
lung which had gone on during the life of the patient. Into 
the appearances of the parts I need not enter further than 
to say that they showed a distinctly peculiar broncho-pneu- 
monia, and that in each case there had been a moribund 
condition associated with vomiting for some days before 
death. Now it is obvious that such a condition has no 
right to the position of a disease, it would never have oc- 
curred had the circulation of the patient been at its proper 
tension. It was the result of an ebbing life, not a disease 
which caused his death. So it is with the gastro-malacia 
of children. It is the result of exhausting disease of any 
kind, and is virtually, if not literally, a post-mortem 
change. 



WORMS. I35 



CHAPTER VIII. 

WORMS. 

Four varieties of worms infest the alimentary canal of 
children — the oxyuris vermicularis, the ascaris lumbricoides, 
the taenia mediocanellata, and the taenia solium. I name 
them in the order in which they are most frequently met. 
The first two are nematodes or thread worms, and are much 
more common than the cestodes or tape worms. The 
oxyuris vermicularis or small thread worm inhabits the 
lower part of the colon, particularly of children. It is a 
fusiform or whitish worm, the female being from a quarter 
to half an inch in length. The male is smaller, and usually 
with a curl of its more blunted tail. The eggs are oval, 
with the surface flattened, and usually contain a formed 
embryo. They are said to be introduced by the mouth and 
hatched in the stomach, whence they pass onwards to their 
habitat in the large intestine. According to Kuchenmeister 
one person is a sufficient host for all stages of the worm, 
but Leuckart considers that the ova must be discharged and 
taken into the stomach, there to be partially digested, and 
the embryo set free before the worm can come to maturity. 
This is not a question of much importance, for it is admitted 
that one and the same child can act the part of a second 
host by re-infecting itself — an easy matter — by means of the 
fingers, which are used indiscriminately for scratching the 
irritated outlets and conveying food to the mouth. 

The ascaris lumbricoides, a round worm, is not at all unlike 
the common garden worm, but paler and more tapering. The 
male measures four to six inches, and is smaller than the 



I36 THE DISEASES OF CHILDREN. 

female. The latter is ten or twelve inches in length, and is 
often seen, when it has been subjected to slight pressure, 
with a bundle of processes hanging from its ventral surface : 
these are the extruded ovaries. The eggs are oval, 3^ inch 
in length, have a nodulated shell, are produced in large 
numbers, and do not contain a formed embryo at the time 
of their discharge. It is important to bear the character- 
istics of the ova in mind, because the round worm is some- 
what obstinate in resisting treatment. It does not reveal its 
presence in the stools as a seething mass of thread worms 
do, and microscopic examination of the stool may be neces- 
sary to determine its presence. It inhabits the small intes- 
tine, and is seldom solitary. Any number may be found, 
often from two or three to five, and occasionally much larger 
numbers. The ova are very indestructible, they remain 
dormant for a long period, and are taken into the stomach 
by means of unwashed food and unfiltered water. 

The tape worms (taenia solium and taenia mediocanellata) 
are far less common than either the ascaris lumbricoides or 
the oxyuris, but they are occasionally present even in infants 
if they have been weaned, and in older children they are not 
uncommon. Inasmuch as the same treatment is efficient 
for both T. solium and T. mediocanellata, and the symptoms 
do not differ for either, it is not a matter of much practical 
moment to distinguish between them, but, shortly stated, 
the taenia mediocanellata or beef tape worm is much more 
common than the taenia solium or pork tape worm; it is 
thicker and tougher generally, it has a uterus which is much 
more finely subdivided, and the head is provided with 
suckers but not with hooklets. The anterior sucker of the 
taenia solium is provided with hooklets. The ripe segments 
or proglottides are passed, and the ova distributed in this 
w T ay. They are then swallowed and become the cysticercus 
of the next host, the cysticercus in turn becoming the 



WORMS. 137 

mature tape worm by passing with food, etc., into the in- 
testinal canal of man. Tape worms require nine or ten 
weeks to reach maturity, so that if, after the administration 
of anthelmintics, the worm passes minus its head, that time 
will probably elapse before segments again begin to appear 
in the faeces. Some time ago, a girl of eleven years old 
was under treatment at the Evelina Hospital for tape worm. 
The oil of male fern effected the passage of a great length 
of worm, but not of the head. She was directed to take no 
more medicine until she should again see the joints of the 
tape worm, when she was to return, and on several subse- 
quent occasions the treatment failing to procure the expul- 
sion of the head, she reappeared at intervals of nine to 
eleven weeks. 

Florence C, aged eleven, came first under my care on 
June 18, 1878. A drachm of the oil of male fern was pre- 
scribed in the usual way with castor oil. She reappeared on 
September 6, and was under treatment till the 24th ; from 
November 29 she was under treatment till December 6 ; 
from February 14 till May 2; July 1 1 till September 20; 
on December 12 she came again, and at this her last attend- 
ance she took three drachms of the ext. filicis liquidum for 
a dose. In every instance the worm was detached close up 
to the head, but the head itself was never found. 

Symptoms and Diagnosis. — All sorts of symptoms have 
at one time or another been ascribed to worms. They have 
mostly been nervous, such as convulsion, epilepsy, cramp, 
choreic movements, or nightmare, and have been supposed 
to be due to some reflex nervous discharge set going by the 
local irritation. But it is very doubtful whether any are of 
diagnostic importance. The presence of worms can only 
be diagnosed with certainty by finding them or their ova in 
the evacuations or about the anus. The habit of picking 
the nose is the popular indication, but it is often no indica- 



I38 THE DISEASES OF CHILDREN. 

tion at all. Pruritus ani is of more value, and when it is ob- 
served should always lead to a careful inspection of the 
faeces, and even to the use of enemata with the view to de- 
tecting the worms themselves. Of other symptoms, such as 
irregularity of pupils, discoloration round the eyes, tumidity 
of the abdomen with colicky pains, diarrhoea, variability of 
appetite, etc., they need only to be mentioned to show that 
they can have no special significance although they may 
probably be some of the many symptoms of feeble health, 
impaired digestion, and irregularity of the bowels, which are 
often present where worms abound. The ascaris lumbri- 
coides, however, inhabiting, as it does, the small intestine, 
and often in large numbers, is apt to wander into the 
stomach, and is sometimes associated with very acute symp- 
toms. Sudden attacks of fever and vomiting are apt to 
supervene and to assume even an aspect of a bad form of 
gastritis or of grave cerebral disease, when a round worm is 
vomited, or perhaps many, and the disturbance is at once at 
an end. The round worm would seem to be particularly 
prone to induce convulsions. Nor need we wonder that 
such is the case, inhabiting the intestine, as they may do, by 
hundreds, and at a time of life when the nervous system has 
not yet reached the stable condition it assumes in healthy 
adult age. Dr. West has, however, seen very severe con- 
vulsions with thread worms, and other authors have equally 
noticed the liability to nerve disturbances which exist with 
the tape worm. 

Thread worms, collecting in great numbers in the rectum, 
are apt to excite local irritation, mucous diarrhoea, prolapsus 
ani, and the occasional passage of blood from the bowels. 
In the male they may excite priapism, and some of the symp- 
toms of stone. Frequent micturition is a common symptom 
of their presence, and I have occasionally noticed haematuria 
also, and the uneasy sensations about the genital organs 



WORMS. 139 

may induce the habit of masturbation. In the female, a puru- 
lent discharge from the vagina is by no means uncommon. 
Worms of any kind are liable to occasion a mucous diarrhoea, 
associated with a good deal of tenesmus. 

Tape worms give rise to fewer local symptoms, but they 
are more often associated with progressive and even marked 
emaciation. 

The symptoms of worms are, as' I have said, none of them 
pathognomonic, so that it is impossible to make a diagnosis 
off-hand. Supposing that a child is emaciating slowly, has 
a frequent cough, occasional diarrhoea, perhaps febrile attacks, 
and sleeps badly at night, it might equally well be suffering 
from commencing tuberculosis as from worms. It is indeed 
only by observation that the question can be settled. In all 
cases of doubt an aperient should be given, and the evacua- 
tions carefully examined. Treatment of this kind should 
in most cases, we may hope, enable us to clear up the diffi- 
culty. 

Treatment. — Worms, like tinea, usually accompany a state 
of health which, if it cannot be called bad, is yet below a 
normal standard ; and, for one child in whom nothing but 
health can be detected, there will be many who are pale, 
thin and unkempt. Possibly in the case of tape worm the 
feeble health may in part be due to the presence of the para- 
site, but this can hardly be the case for other forms of worms, 
and, like tinea, therefore, the existence of any form of intes- 
tinal parasite may be considered an evidence of the need of 
tonic treatment and better hygiene. As a general prophy- 
lactic, salt is to be commended, and I am of opinion that this 
is a necessary article of diet, which is much neglected in 
feeding children. But general principles of this kind must 
be associated with special treatment directed to the death 
and expulsion of the worm, and this will vary for the differ- 
ent species. 



I40 THE DISEASES OF CHILDREN. 

Thread worms should be attacked locally by means of 
enemata. A drachm of sulphate of iron may be added to a 
pint of infusion of quassia, and a third part of it injected on 
alternate mornings. Simple salt and water is recommended 
by some, lime-water by others. Enemata of this kind may 
be continued as long as may be necessary, and are moder- 
ately certain ol success. But mothers and nurses often 
bungle over their administration, and either frighten the 
child so much that repetition of the treatment is impossible, 
or the fluid is allowed to run away again as soon as it is in- 
jected, when naturally enough a failure results. The lower 
bowel should be first emptied by an injection of warm soap 
and water. The child should lie upon a bed with its buttocks 
elevated, and the tube of the syringe should be passed gently 
within the inner sphincter. The fluid, previously warmed, 
must be injected with some little force, that it may be lodged 
in the upper part of the rectum, otherwise expulsive efforts 
will be immediately excited, the fluid will not reach its desti- 
nation, and the desired end may not be secured. Even in 
such case, however, by compressing the anus between the 
buttocks, or by a firm pad, the expulsive effort may be over- 
come, and the enemata retained. If the enemata be not given 
at bedtime, the child should be kept on the bed for an hour 
or so after its administration. Attention to details of this 
kind determines the success of the treatment. Compared 
with it other measures are very inefficient. Brisk purgatives, 
such as calomel with jalap (F. 33), will cause the expulsion 
of many worms, but their action is not radical, and it is better 
therefore to trust if possible to enemata. They may be com- 
bined with an internal treatment of sulphate of iron and 
compound decoction of aloes (F. 34); and iron in some form 
should be continued for some time after the extermination 
of the worms. The irritation about the rectum is best re- 



WORMS. 



I 4 I 



lieved by smearing the parts with a combination of mercu- 
rial ointment and glycerinum acidi carbolici in equal por- 
tions. 

The round worm is best treated by santonine, which may 
be given in doses of one or two grains three times a day, 
either disguised in bread and honey, or in a teaspoonful of 
confection of sulphur or confection of senna. After two days 
of this treatment some purgative should be administered, §ss 
of castor oil mixture (F. 3), or two grains of jalap resin in 
milk, being as good as any. Atonic treatment of iron is to 
be continued for some time after the dislodgement of the 
worms. 

[Other remedies are fluid extract of senna and spigelia 
and oil of chenopodium. With the first it is not necessary 
to give a purgative. The second may be given dropped 
upon a lump of sugar, three times a day ; the third dose 
being followed by a brisk cathartic, or, it may be, adminis- 
tered in the form of an emulsion with castor oil, thus : 



R. 



Olei Chenopodii, 
Olei Ricini, 
Olei Cinnamomi, 
Mucilag. Acacise, 



. fijij. 

. f*jss. 

. ni v. 

q. s. ad f ^iij. 



M. 



S. — One teaspoonful three times daily, for a child of two years.] 



Many drugs have been proposed for the destruction of 
tape worms, pomegranate root bark, turpentine, cusso, and 
male fern being most prominently supported. But with 
children, as with adults, although it is advisable to have 
many strings to the bow, the oil of male fern is the one 
remedy in almost exclusive use. It is a drug which is ap- 
parently harmless even in doses of considerable size. A 
drachm to a drachm and a half of the liquid extract is a 
proper dose. It may be given as an emulsion with 3ss of 



142 THE DISEASES OF CHILDREN. 

pulv. tragacanth. co.* either in milk or in any sweetened aro- 
matic water that may be pleasant to the child. The anthel- 
mintic must be given after a fast, and with the intestine pre- 
viously emptied of its contents by castor-oil. After an early 
tea the castor-oil should be given, and early the next morn- 
ing — as early as possible so as to avoid too prolonged a 
fast — the oil of male fern ; the child lies quiet in bed the 
while, and two or three hours later a second dose of oil is 
given, after which food may be given when required. Should 
this treatment fail, turpentine should be given — twenty drops 
of oil of turpentine three times a day — the food being con- 
fined to liquids. The turpentine may be given as in formula 
3 1 , and must be followed up by a purgative every day or two. 
[Powdered kameela, given in syrup, and pumpkin-seeds, 
beaten up with sugar into an electuary, are also used. These 
are sometimes more successful than male fern. The dose 
of kameela is twenty grains to a drachm ; of pumpkin-seed, 
from one to two drachms ; each to be followed by a purge.] 

* Pulvis's Tragacanthse Compositus, Br .P., contains : 
Tragacanth, in powder, 1 

Gum acacia, in powder, \- .... I ounce. 

Starch, in powder, 
Refined sugar, in powder, . . . . .3 ounces. — Ed. 



INTUSSUSCEPTION. 1 43 



CHAPTER IX. 

INTUSSUSCEPTION. 

Intussusception is where one piece of intestine passes into 
a piece immediately continuous with it, the intussusception 
being the tumor so formed. In the common kind the ileo- 
caecal valve and the lower part of the ileum are received into 
the colon, and the tumor is composed of the colon externally 
(ensheathing layer), the ileo-caecal valve and caecum within 
this ( returning layer), and the lower part of the ileum, inter- 
nally (entering layer). In this form, therefore, the ileo-caecal 
valve is always the lowest part, and supposing, as is often 
the case, that the intussusception passes into the rectum, it 
is that part which is felt by the finger within, or which pro- 
trudes from the anus. Much more rarely a piece of the 
ileum passes through the ileo-caecal valve ; or some other 
part of the large or small intestine is affected away from the 
valve. Further, as might be expected, the direction of the 
intussusception is almost invariably from above downwards ; 
although one or two cases are on record in which the re- 
verse direction has obtained, and a piece from below has 
passed into that which lies above it. 

Pathology. — It would not be difficult to occupy a good 
deal of space in discussing this question, but not much good 
would be gained thereby. I shall, therefore, be content 
with insisting upon one or two facts which seem to be all- 
important in their bearing upon it. And first, let it be no- 
ticed that by far the larger number of cases of intussuscep- 
tion occur in infants under two years of age — most of them 
under a year ; secondly, that small intussusceptions in the 



144 THE DISEASES OF CHILDREN. 

length of the small intestines are by no means uncommon 
in the bodies of children who have died of all manner of 
diseases, and it is clear, from the absence of any symptoms 
during life, and from the want of any local morbid appear- 
ance in the part concerned after death, that the displace- 
ments must have occurred at the time of death or but very 
shortly before ; and thirdly, that the common seat of the 
affection which causes symptoms during life is ileo-caecal. 

Now, what do these facts indicate ? Not much, perhaps, 
as they stand, and yet they are very significant. Those who 
have been in the habit of seeing experiments performed upon 
the lower animals, well know that at the moment of death 
there is not infrequently a vigorous and persistent peristaltic 
action of the intestines. The same thing is apparent as a 
clinical fact in the evacuation of the bowel, which so often 
happens at the time of death in all classes of patients. This 
is no mere relaxation of the sphincters. They become re- 
laxed truly, but the weight of the buttocks and of the soft 
parts would be amply sufficient to restrain any outflow of 
faecal matter, were it not that the intestine acts vigorously 
and persistently after death. The intestine, so to speak, has 
a death struggle, and dies slowly ; and in so doing its mus- 
cle acts less regularly, and intussusception is an occasional 
consequence. It is impossible to watch a healthy infant for 
even a few minutes, and not see that in its every movement 
there is convulsion and disorder. The frequency of intes- 
tinal disorders in children is an expression of the same fact ; 
and so, also, no doubt, in large part, is the occurrence of 
intussusception. Intussusception is chiefly a disease of young 
children, because the muscular coat of the bowels is as yet 
too easily excited, and is prone to act energetically. That 
the ileo-caecal valve and lower part of the ileum form the 
intussusception in so large a majority of the casus, is also 
worth consideration ; for the anatomical arrangement is 



INTUSSUSCEPTION. 1 45 

such that it may be almost said to form a natural prolapse, 
or at the least would readily become one upon the slightest 
alteration of the natural relations of the parts either as re- 
gards their relative positions or relative capacity. It has 
been suggested that some congenital laxity in the attach- 
ments of the caecum, is the reason of the frequency of ileo- 
caecal invagination ; but, granting the condition, it is not 
clear that it would favor the occurrence of this particular 
displacement, and no proof has yet been given that any such 
condition exists. On the other hand, the reasons I have 
already mentioned seem sufficient to explain the observed 
phenomena, and the more so if we allow further for the pos- 
sible passage of indigestible food or of inspissated faecal 
matter. 

Morbid Anatomy. — On opening the bodies of children 
who have died of intussusception, there may be nothing ab- 
normal to be seen at first sight. The small intestine, more 
or less distended, occupies the front of the abdominal cavity, 
and the colon is not visible. When the small intestine is 
displaced, probably some twisted condition of the mesentery 
will become apparent, and the caecum and more or less of 
the colon will be found absent from their natural position. 
The colon will appear to take origin from a knot-like bulb 
of bowel, perhaps lying in the right loin or in some part of 
the transverse or descending colon. The small intestine 
passes into a node of bowel, and this when taken between 
the finger and thumb feels doughy and inelastic. The 
intussusception gives a livid appearance to the tumor, and 
there is often ecchymosis or lymph about the neck of the 
knot. The condition of the intussuscepted bowel will of 
course vary with the length of time that the affection has 
existed in an acute form. But it is generally more or less 
twisted or coiled, from the inclusion of the mesentery ; of a 
dark claret color from congestion or extravasation of blood 



I46 THE DISEASES OF CHILDREN. 

into its substance, or ash-colored from sloughing of the sur- 
face of the mucous membrane ; and the coats of the included 
bowel are thickened by oedema and inflammatory products. 
Bearing in mind that the experience of the post-mortem 
room is based upon cases of exceptional duration or severity, 
it may be worth stating what have been the effects of post- 
mortem attempts at reduction in such cases. Inflation has 
never done more than partially reduce the intussusception ; 
hydraulic pressure applied by passing a half-inch bore india- 
rubber pipe, connected with the water-tap, up the rectum, 
and then gently turning on the tap till the requisite pressure 
is obtained, has reduced a bad case with ease; traction upon 
the small intestine at the neck is not often successful ; and 
manipulation, such as that applied to a hernia, from outside, 
usually reduces the greater part of the prolapse, if applied 
with care, but fails to accomplish the return of the last two 
or three inches of bowel — the part about the neck of the 
intussusception having by that time become tight from the 
squeezing and traction combined, whilst the neck itself is 
liable to split. In two or three cases I have found it impos- 
sible by any means to effect complete reduction without 
doing so much local damage as would have deprived an 
operation of any chance of success had the child been still 
alive. The obstacles to reduction are chiefly two. First, 
the spiral twist or curve which the intussusception assumes 
around its mesentery, and which depends upon the inclusion 
of the mesentery. It is almost impossible, for this reason, 
to make any adequate traction upon the bowel in the proper 
axis. And, secondly, the swelling of the coats of the inclu- 
sion due to oedema, extravasation of blood, or the formation 
of inflammatory products, — occasionally lymph, — about the 
neck of the sac, or lymph between the peritoneal surfaces of 
the entering and returning layers ; these offer an obstacle to 
any return by direct traction ; but they do not usually offer 



INTUSSUSCEPTION, 1 47 

much hindrance to reduction by other methods of manipu- 
lation, such as gentle pressure. 

The experience of the post-mortem room is on the whole 
decidedly adverse to the chances of reduction when the case 
has existed sufficiently long to produce much oedema or in- 
flammatory thickening of the coats of the bowel. And it 
may also be remarked that, supposing reduction is effected 
in any such case, there will still exist a more or less intense 
enteritis in some inches of the bowel, which must make the 
prognosis one of the most guarded nature for some days 
after. 

Symptoms. — Vomiting ; the expulsion of blood and blood- 
stained mucus per anum ; the presence of an elongated 
doughy tumor in some part of the colic region, or the pro- 
trusion of a polypoid mass of mucous membrane from the 
anus ; pain, and the sudden supervention of such symptoms 
of collapse as pallor, a sunken eye, and rapid pulse. 

These, it will be noticed, are the symptoms of strangu- 
lated hernia, with the substitution of the passage of bloody 
mucus in intussusception for the obstinate constipation of 
hernia. But, when we talk thus of the symptoms of intus- 
susception, we are ignoring a very important clinical fact — 
viz., that the symptoms necessitate a recognition of two 
kinds of intussusception — strangulated and non-strangu- 
lated — or, as some would have it, acute and chronic. 

An intussusception may exist without any constipation, 
without the passage of any blood or mucus, and indeed 
without any characteristic symptoms of any kind. Some 
years ago a child of ten months old was brought to me as 
an out-patient; it was cutting its teeth, was feverish, rest- 
less, and had a dry, furred, reddish tongue. The abdomen 
was full, but not tender ; it was quite supple, and after care- 
ful examination nothing could be felt. It was not sick, and 
there was no passage of blood. A few days after the mother 



I48 THE DISEASES OF CHILDREN. 

came to say the child had died ; and, not knowing why such 
a result had happened, a post-mortem was made. I rather 
expected to find some form of enteritis ; but, in addition 
thereto, there was an elongated intussusception of the ileum 
into the colon, occupying the middle of the transverse colon, 
of which I had had no suspicion. Other similar cases are 
on record, and others again where cholera infantum, typhoid 
fever, etc., have been mistaken for intussusception. It is, 
therefore, important to remember that, unless it is strangu- 
lated, the intussusception may be obscured by symptoms of 
catarrhal enteritis. A careful examination of the abdomen 
for the presence of a tumor is the best safeguard against such 
a mistake ; but even this may mislead, the small intestine 
becoming distended and hiding the colon. 

The symptoms of strangulation of the intussusception are 
usually well-marked. Although the child may have been 
ailing previously, the onset of acute symptoms is usually 
sudden. There is the cry of pain, obstinate vomiting, con- 
stipation, and the passage of blood or bloody mucus. And 
in addition to, or even before these, there is the aspect of 
severe illness, which comes on early, and is well worth at- 
tention, as suggestive of serious mischief, when other more 
distinctive features are yet in abeyance. The vomiting of 
infancy is so common an affection that it is liable to pass 
without much attention ; but vomiting, with restlessness and 
abdominal pain, and the quick onset of extreme pallor and 
a sinking hollow under the eyes, are a trio which should 
always compel attention. Death from intussusception may 
ensue with no other symptoms than these within twenty-four 
or thirty-six hours. With regard to the presence of blood 
in the evacuations, it has been shown by my colleagues, Dr. 
Hilton Fagge and Mr. Howse,* that it does not necessarily 

* " On Abdominal Section for Intussusception in an Adult." Medico-Chir. 
Trans., vol. lix. 






INTUSSUSCEPTION. 1 49 

mean strangulation of the intussuscepted bowel in the sense 
that we speak of a strangulated hernia — viz., as the prelimi- 
nary of gangrene ; for it may be present, even from the first, 
in cases where the symptoms run a chronic course, and 
where even at last no gangrene or ulceration of bowel is 
found. It may, however, be concluded that it indicates 
some constriction of the vessels. Such a condition is com- 
patible with the sustentation of the life of the tissues involved, 
particularly if the constriction is, as is probably not uncom- 
mon, intermittent. It has also been pointed out that in many 
of the cases in which the bowel has sloughed away no blood 
has been at any time present in the motions. The symp- 
toms have been those, indeed, of enteritis or peritonitis, and 
not those supposed to be characteristic of intussusception. 

The confirmation of our diagnosis is not the only advan- 
tage derived from ascertaining the presence of an abdominal 
tumor. It has been asserted that by observing the behavior 
of the tumor we may also learn something of the condition 
of the invagination ; that if the tumor changes its position 
from time to time, we may conclude that the intussusception 
is not yet adherent, and therefore has not yet commenced 
to separate by sloughing. But it cannot be inferred that, 
because the tumor thus alters its position, therefore it can 
be reduced. The parts may not be sloughing — may not 
perhaps even be adherent — and yet may be so cedematous 
or inflamed as to be incapable of reduction ; and in infants, 
when separation of the intussusception by sloughing offers 
no chance of recovery, we want to know whether, in any 
particular case, the intussusception is reducible, and for this 
any change in the position of the tumor offers no trust- 
worthy guide. 

To sum up with regard to the symptoms. Intussuscep- 
tion may exist for weeks, perhaps even for months, without 
giving rise to any severe illness, and may be characterized 

13 



150 THE DISEASES OF CHILDREN. 

only by periodical attacks of constipation, abdominal grip- 
ing, and vomiting, and by the occasional passage of a little 
blood. Palpation of the abdomen should reveal the pre- 
sence of an elongated tumor, which alters in position, in 
shape, and in hardness from time to time. But, as com- 
monly seen, intussusception is an acute affection which runs 
its course in at most three or four days, and the more usual 
symptoms are abdominal pain and distension ; vomiting ; 
constipation ; the passage of blood-stained mucus ; and 
often the presence in the rectum of a tumor with character- 
istic features. 

Course and Duration. — The natural tendency of every 
intussusception is to become nipped at its neck by the bowel 
which insheathes it, and sooner or later to become inflamed 
and to slough off. But sometimes the nipping is long 
before it happens, and the sloughing off process is almost 
never effected in infants. The spontaneous cure of an intus- 
susception by sloughing of the invaginated mass is a result 
which may be hoped for in children of six or eight years, 
and in adults ; but in infants under two years the disturb- 
ance set up by the inflammation of the bowel is almost 
invariably fatal in from thirty-six hours to three or four 
days — unless it can be remedied by treatment. 

Prognosis. — When the onset is acute, the treatment is 
generally unsuccessful, and the child dies ; but enough cases 
have terminated favorably under treatment to allow of a cer- 
tain amount of hope. 

In chronic cases the issue is more doubtful ; the risk of 
the ultimate supervention of strangulation must evidently 
be considerable ; but some cases seem to right themselves 
under treatment, and of this the following case is probably 
an instance. 

A boy of three and a half years was suddenly seized one 
evening with pain in the abdomen, which caused him to 



INTUSSUSCEPTION. I 5 I 

scream violently, and he was frequently sick. These symp- 
toms continued for three days and two nights, when he got 
quite well. He passed no blood by the bowels. Three 
months later, he was taken in the same way, and this time 
he passed a little blood from the bowels without any strain- 
ing. For three weeks he vomited repeatedly, and passed 
frequent loose motions, but no blood. The sickness then 
ceased for a day or two, but as it returned again, he was 
brought to the hospital. He had had a great deal of castor- 
oil. He lay quiet in his mother's arms, but frequently cried 
with abdominal pain, which came on in paroxysms. His 
lips and tongue were dry and furred; pulse 120. On ex- 
amining the abdomen, it was not distended, but midway 
between the ensiform cartilage and the umbilicus there was 
an elongated sausage-like tumor, rather ill-defined in its 
outlines, but yet suspiciously like an intussusception. He 
was taken into the hospital under my colleague Dr. Taylor, 
who agreed with this diagnosis. He was put upon small 
doses of opium and fed carefully, when the pain subsided 
and the tumor slowly disappeared. He was kept under 
observation for six weeks, and at the end of that time no 
lump could be felt in any part of the abdomen, except in 
the region of the caecum, and this I attributed to a fecal 
collection. I have notes of other similiar cases. 

Treatment. — By some means or other the invaginated 
portion of an acute intussusception must be returned. 
Opium should be given in drop doses as often as necessary 
to quiet the action of the bowel. Small doses of belladonna 
and hydrocyanic acid may also be found useful. The abdo- 
men should be covered with a warm fomentation or good 
warm poultice. 

If the symptoms are not relieved by such measures, re- 
duction must be attempted without any delay, either by 
manipulation, by inflation, or by the injection of water or 



152 THE DISEASES OF CHILDREN. 

oil. In any case, chloroform should be administered. 
When the abdominal muscles are well relaxed the tumor 
may be kneaded between two hands — possibly it may be 
fixed between the fingers and thumb of the right hand, and 
gently squeezed. In this way an intussusception may be 
partially reduced, but I have not seen complete reduction so 
effected. Inflation is effected by a bellows. To this a stout 
piece of india-rubber tubing, with a vaginal end, is attached, 
and passed well into the rectum. The buttocks are held 
tightly round it, and air is then pumped into the colon ; an 
assistant at the same time applying gentle friction to the 
surface of the abdomen. The amount of force required 
must depend upon circumstances. Replacement of the 
bowel can usually only be effected by considerable disten- 
sion of the whole colon, and distension of the colon some- 
times requires a good deal of rather forcible pumping to 
compass it. 

If success is not achieved by inflation, water should be 
injected. The practice usually emploped is to use an ordi- 
nary enema apparatus, and to inject as much tepid water as 
may be possible or necessary. Nothing appears more 
simple or easier to carry out efficiently than this plan, but 
as a matter of practice it is generally difficult to inject 
enough water with a force so carefully graduated, as to be 
harmless, and yet sufficiently continuous to be successful. 
In many cases the greater part of the rectum is already filled 
by the intussusception, and the water returns by the side of 
the tube as fast as it is injected. No adequate distending 
force is exerted in such a case, and it becomes necessary to 
consider the question of an operation. But before resorting 
to this, as I think, desperate measure, let me recommend the 
trial of a modification of the usual plan of water distension, 
which both experiment and practice would seem to show is 
deserving of attention. The rectal tube is connected with 



INTUSSUSCEPTION. I 5 3 

an improvised water-cistern placed high above the bed and 
thus is obtained a more equable and forcible distension. 
The tube must of course be under careful control, and inas- 
much as greater force is called into play, a greater risk of 
rupturing the bowel is run. But then what are the alterna- 
tives? If left alone, the child will probably die. If the 
abdomen be opened and the bowel returned, it will probably 
sink within a few hours of the operation ; so that no risk 
can well be greater. It would be folly to affirm that any 
distension of the bowel, sufficiently forcible to return any 
considerable length of an intussusception, is free from risk ; 
and both inflation and the injection of water are very liable 
to split the peritoneal covering of the intestine and may rup- 
ture the bowel : still, provided that the requisite distension 
cannot be procured without it, the end assuredly justifies the 
means. Mild means are to be attempted in the first instance, 
and of these I count opium, given internally; manipulation ; 
inflation under chloroform ; and copious enemata. Next in 
severity may be placed the more forcible distension I have 
described ; and not till all other measures have been tried 
and have failed should the abdomen be opened. 

With regard to the operation of laparotomy, the results 
at present are that but few cases have been successful out of 
many. Nor can an operation of such magnitude, performed 
upon subjects of such tender age, no matter what improve- 
ments are adopted, ever be otherwise than very dangerous. 

But there may still be a future in store for it if all un- 
necessary delay is avoided. Intussusception is so usually 
fatal that it should be taken in hand at once and treated ; 
and, if the treatment be unsuccessful, the abdomen should 
at once be opened. Early operation gives the best security 
against finding the intussusception irreducible, and the pro- 
longed operation which irreducibility involves has probably 
had much to do with the great fatality which has hitherto 



154 



THE DISEASES OF CHILDREN. 



attended the resort to surgical measures. The method of 
operation is a surgical question ; I shall therefore only say 
that it consists in making an incision in the median line of 
the abdominal wall, opening the peritoneum, finding the in- 
tussusception, and working it back at the neck, much as a 
hernia is reduced. Sometimes traction reduces it readily. 
Antiseptic precautions should be adopted, but great care 
should be exercised not to expose the surface of the child 
to cold. There is a tendency to neglect this precaution 
in the present age of sprays and vapors, though few are 
more absolutely essential for the well-being of the child. I 
am convinced that if the abdominal section is to be success- 
ful in infants, the operation must be conducted with all 
possible celerity, and the surface — whilst it is going on — 
must be uncovered as little as possible. 

[Prof. John Ashhurst, Jr., in an article on " Laparotomy for 
Intussusception," in the American Journal of Medical Sci- 
ences , July, 1874, gives a table of thirteen previouly reported 
cases of laparotomy for invaginated bowel. From this 
table I have extracted five cases which occurred in children 
and have given below Prof. Ashhurst's conclusions : 



6 












* z 
c E h 




< 


Sex 


Opera- 


Symptoms before 


Duration 






AND 

Age. 


tor. 


the 
Operation. 


of 
Disease. 


H 

p 


H < < 

< a g 

K fc « 


Remarks. 


5 












b h h 

p>->o 




Male, 


Gerson. 


Symptoms of obstruc- 


Not 


Died. 


A few 


Bowel ruptured, and 




12 




tion, with hemor- 


mentioned 




hours. 


operation aban- 




weeks. 




rhage from the 
bowels. 








doned. 


8 C 


Spencer 


Not specified. 


4 days. 


Died. 


5 hours Child almost mori- 




4 mos. 


Wells. 










bund at time of 
operation. 




Child. 


Athol 


Not specified. 




Died. 








Johnstone. 










12 


Female, 


Wein- 


Symptoms of obstruc- 


3 days. 


Died. 


6 hours. Died in convulsions ; 




6 mos. 


lechner. 


tion, with great 
pain, vomiting, and 
hemorrhage from 
the bjwels. 








peritonitis found 
at autopsy. 


13 Female, 


Hutchin- 


Symptoms of obstruc- 


1 month. 


Recov- 




Disin vaginati n 


■2 years. 


son. 


tion merely ; intus- 




ered. 




effected without 








susception protrud- 








difficulty. 








ed from anus. 











INTUSSUSCEPTION. 



iS5 



" Inspection of this table shows, in the first place, that 
there is no encouragement to repeat the operation in very 
young infants. The only instances in which it has been re- 
sorted to during the first year of life have all terminated 
fatally (Gerson, Wells, Weinlechner). But when it is re- 
membered that of Pilz's 162 cases (all occurring in children), 
no less than 91 were in infants less than a year old, it will 
be seen how large a proportion of cases must at once be put 
aside as unfitted for operative treatment. It is very true that 
the fatality of intussusception at this early age is enormous, 
the mortality being according to Leichtenstein's elaborate 
statistics no less than 86 per cent. But the case is very dif- 
ferent from that, for instance, of an operation for imperforate 
rectum, for in this condition there is necessarily no hope but 
in an operation, whereas in the case of intussusception ex- 
perience shows on the one hand that, even at this age, a 
certain number do recover without operation, and that on 
the other hand, as might be expected, operative treatment 
is in such cases of no avail. 

" In the second place, the table shows that in what may be 
called acute cases, those, namely, in which in addition to 
symptoms of obstruction there are evidences of strangulation, 
such as peritonitis and intestinal hemorrhage, a resort to 
operative interference will be productive of no benefit. These 
cases are, on the other hand, as justly remarked by Mr. 
Hutchinson, precisely those in which there is most hope of 
recovery by sloughing of the invaginated portion. 

" There remains then a limited number of cases, in not very 
young infants, in which the symptoms are those of obstruc- 
tion merely, without intestinal hemorrhage or peritonitis, 
and in which, when other measures fail, the question of 
operation may properly be considered."] 

In chronic intussusception great reliance may be placed 
on the free administration of opium and belladonna. This 



I56 THE DISEASES OF CHILDREN. 

form of intussusception occurs usually in older children, and 
four or five drops of opium and ten drops of tincture of bel- 
ladonna may be given every four hours to a child of five or 
six years old. Should these fail, inflation or water disten- 
sion must be tried, and as a last resort an operation must be 
discussed. 

[In both forms of intussusception it is important to so 
regulate the diet that the strength may, as far as possible, be 
conserved. The quantity of food must depend upon the 
condition of the stomach, and in selecting the quality it is 
necessary to choose what is readily digested and so as- 
similable that little residue remains to form faecal masses.] 



MEASLES. 



157 



CHAPTER X. 



MEASLES. 



Measles (Morbilli). — Rubeola is another term which be- 
longs to this disease ; but of late and abroad it has also been 
applied to Rotheln, and had, therefore, better be discarded. 

Incubation. — By this is meant the time between the 
actual introduction of the poison and the appearance of the 
first symptom of illness. This has been established (1) by 
experiment, measles having been introduced by inoculation 
in Edinburgh, Italy, and Germany; (2) by the careful ob- 
servation of outbreaks of the disease in what may be called 
virgin soil, such as that in the Faroe Isles, by Panum ; 
(3) from the records of actual practice as it occurs in our 
own climate. From all these sources it would appear that, 
though liable to modification within limits of three or four 
days either way, the incubation period centres around ten 
days. 

For instance, E. and F., of eight and ten, were at school 
from the 10th or nth to the 19th of the month, with a child 
who then sickened with what was subsequently found to be 
measles. The child sneezed so much on the 19th that the 
mistress particularly noticed her. And on the 25th E. began 
to be poorly ; on the 30th, a punctiform red rash appeared 
on the palate, and she left school for giddiness ; and on the 
31st, the eruption appeared on the face, and quickly spread 
downwards to trunk and legs. F. was sleepy, and had 
headache on the 30th ; on the 31st the evening temperature 
rose to 100.4 , and the symptoms of cold increased; on the 

14 



I58 THE DISEASES OF CHILDREN. 

1st, the punctiform eruption appeared; and on the 3d, the 
rash was noticed on the skin. 

These cases may also well illustrate the impossibility that 
often exists of exactly fixing the date of the introduction of 
the poison. Both children were at school, E. eleven days, F. 
eleven or twelve days after the source of infection left, but it 
is not improbable that the house or room in which they were 
was infected, and that the actual reception of the poison by 
F. was of later date than that by E. 

Prodromal Stage. — This is characterized by what is com- 
monly called a cold, and lasts about four days. The child 
is drowsy, sometimes remarkably so, and thus may give an 
early suggestion of what is coming ; it has headache. Then 
come redness of the eyes and lids, and running from the 
nose. Xext there is a dry cough and the evening tempera- 
ture begins to rise. This coryzal aspect — if the child is 
poorly, which generally means feverish — is very suspicious. 
The palate should now be carefully examined, and not 
infrequently the roof of the mouth behind the hard palate 
may be seen covered with a sharply-defined red blush, with 
a number of minute red papules upon it. Described by 
various independent observers, the value of this blush as an 
initial symptom preceding the eruption by some hours, is 
indorsed by Meigs and Pepper, Henoch, and others, and I 
have seen it well marked in some cases. Barthez and Rilliet 
do not, however, attach any value to it* Other symptoms 
are occasional only, and therefore of little value ; chief 
amongst these are epistaxis and vomiting. 

Eruptive Stage. — The eruption appears about fourteen 
days from the date of infection, or four from the first signs 
of illness. It is first seen about the ears, temples, and face 

* The punctiform rash above mentioned is almost uniformly present, and 
in my experience precedes the cutaneous eruption by almost twenty-foui 
hours. — Ed. 



MEASLES. 



159 



in the form of small, dull, red papules tending to cluster 
more or less in crescentic lines, although not usually 
arranged with any great regularity. In favorable cases its 
course is now rapid ; within ten or twelve hours it will have 
spread to the trunk, and even to the legs, and within twenty- 
four the Lice will be more or less covered with dull red, 
raised, and often confluent, blotches which strangely alter, 
not to say disfigure, the features. The face generally bears 
the brunt of the attack ; it is not usually so thick on the 
trunk, and still less so on the legs. The temperature usually 
mounts, by evening rises and morning falls, for the four 
s preceding the outbreak of the eruption, and then falls 
again rapidly when the rash begins to fade in twenty-four 
or forty-eight hours, and in mild cases it is normal or sub- 
normal by the third or fourth day from the first appearance 
of the rash. 



2asb : —I :v :? 15. 

_ , r eruption 

4th dav if. t. 1 : : : < , 

^ appeared. 

it, 1 :a.6° 
5th day if. T. IC2 : 

E. t. ior.2- 
6th day if. r. ici c 

7. 7, : 
7th day m. t. 97. 7 : . etc. 



? . : : — C 
3d day if. 7 normal. 

f eruption 



4th day if. T. 102.3° 

E. T. io:.S : 
5th day iff. T. 102 ,_ : 

E. T. I02.3 

e. t. 00. ; r . etc. 



I appeared. 



But no great regularity can be depended upon in the pro- 
dromal stage ; the temperature may, with only slight dis- 
turbance previously, run up quickly at, or just before the 
outbreak of the eruption; or the height of the fever may be 
reached before the eruption appears. If the temperature 
remains high after the fourth or fifth day from the appear- 
ance of the eruption, the chest should be carefully examined 
and watched. Very commonly some broncho-pneumonia 
is the cause of this. 



l6ti THE DISEASES MP CHILDREN. 

The eruption soon fades, but leaves the skin somewhat 
marbled by reddish-brown stains for some days afterwards, 
and it is often followed by slight branny desquamation, most 
ble about the face and neck, when the rash has been 
profuse. The pulse is full, soft, and considerably quickened 
during the height of the attack — I20 c to i-icr — and may 
even be intermittent for a few hours ; but it speedily recov- 
ers itself at the first approach of a crisis. The bronchial 
affection is generally the most persistent part of measles. 
The disease is ushered in by a dry* cough, and more or 
catarrh results from this, consequently a loose cough or one 
associated with an excess of secretion, may linger for some 
In many cases no more than this happens, the pul- 
monary* parenchyma remaining healthy throughout, or at 
most showing no other abnormality than harsh breathing 
or an occasional rhonchus or rale. In severe cases the c 
affection is paramount, and we then have to deal with a 
diffused broncho-pneumonia or capillary* bronchitis, 
perhaps a sluggishly appearing or retrocedent eruption, 
pallor of face, lividity of lips, dilating alae nasi, and high 
lever. 

Modifications. — It has been the custom to dc hree 

or four varieties of measles, but it is enough to state that 
measles, like all other exanthems, is liable to van*. The 
typical disease is known by fever, a peculiar eruption, 
and a catarrhal inflammation of the respira: 
Common sense will tell anyone that in very* mild ; 
the catarrh may be absent or the eruption all but so. 
In bad cases, on the other hand, the eruption may be- 
come very dark-colored or even petechial, and the catarrh, 
which is a part of the natural history* of the disease, be 
replaced or added to by a more or I re broncho-pneu- 

monia. In such cases also, it hardly needs the j, the 

eruption may be irregular in its progress, or fitful in its 



MEASLES. l6l 

appearance, and the general indications from pulse, temper- 
ature, and nervous system, are likely to be grave in propor- 
tion. The condition, however, which is described by Bar- 
thez and Rilliet as rougeole anomale is worthy of distinct 
mention, because it calls attention under one term to many 
puzzling cases in which the eruption comes out later or in 
some lagging fashion, and in parts of the body where we 
should perhaps not expect it, such as on the abdomen or 
extremities. Measles may appear first on the buttocks, for 
example, where eruptions of all sorts are so common, and 
should the child have been ill for four or five days with 
acute pneumonia, the real disease might well pass unrecog- 
nized. 

Complications aud Sequelae. — Of these by far the most 
important, because most frequent and most dangerous, are 
broncho-pneumonia and membranous laryngitis, or croup. 
Of others may be mentioned marasmus, diarrhoea, whooping- 
cough, and, as late oncomers in unhealthy children, a tribe of 
glandular and other affections — discharge from the ear, sup- 
purating glands in the neck, caseating mediastinal glands, 
and general tuberculosis. Albuminuria is a rare sequela. 
I have seen it once in the second week. Broncho-pneumo- 
nia, being in a measure part of the natural history of the 
disease, is the most common and the most destructive to life. 
When it comes on suddenly, as it may do in young children, 
the eruption may be slight, but the temperature often arises 
in these cases to 105 ° or 106 , the child becomes pallid or 
livid, and dies in a semi-collapsed state. Naturally there 
are all degrees of pulmonary affection between this the most 
extreme and the milder cases. 

Membranous laryngitis is another common outcome of 
measles. It may attack the child at any time ; most usu- 
ally within a week or ten days after the subsidence of the 
rash. It is probably epidemic in its occurrence — that is to 






1 62 THE DISEASES OF CHILDREN. 

say, is more prone to occur at special times than to attack all 
cases of measles indiscriminately. But from its gravity it 
should never be forgotten, particularly if the laryngeal cough 
has been troublesome or persistent during the fever. 

Diarrhoea is another associate which may either usher in 
or follow the disease, and is described by Henoch as some- 
times being very profuse and dysenteric in character. It also 
is epidemic in manifestation. 

Marasmus I note for this reason, that when very young 
children — a year to eighteen months or two years old — are 
attacked with measles, it may happen that the eruption 
comes out sluggishly, the fever persists, though not to any 
excessive degree — 102 to 103 — the tongue and mouth be- 
come dry and ulcerated or covered with sordes, and rapid 
emaciation takes place. And this, without any pronounced 
broncho-pneumonia, croup, or other fatal accessory. 

Whooping-cough is generally spoken of as being espe- 
cially related to measles, and certainly the impression that 
is left upon my mind as the outcome of experience is, that 
the two affections often follow one upon the other. But . 
when an appeal is made to statistics the association appears 
to be less common than I had anticipated. Of 305 cases of 
pertussis of which I have notes, measles is only mentioned 
as recent in fourteen. There would appear to be some dif- 
ference of opinion also as to the relation which the two 
diseases bear to one another. West speaks of measles as 
following the pertussis. My own experience is contrary to 
this. In all these fourteen cases the measles came first and 
the pertussis closely followed. For instance, a girl aged 
thirteen months, was well till six weeks before admission ; 
then came measles, and after fourteen days pertussis. But 
the cough may follow within a day or two of the outbreak 
of the measles. When measles follows upon pertussis, the 
characteristics of the latter may temporarily disappear. 



MEASLES. 



163 



What the real relation of the one to the other may be, can 
only be a matter of conjecture, but it is probable that for 
measles, pertussis, membranous laryngitis, and varicella — all 
of which seem prone to combine — the presence of any one 
lessens the resistance which a healthy body manifests, to 
the infective power of the others. A child therefore with 
measles would be more susceptible to either of the others 
should it be epidemic at the time. 

Noma and necrosis of the nasal cartilages after measles 
have been recorded. As late results of measles there are 
many indefinite conditions of ill-health when the disease has 
been severe or neglected. It is certainly far from uncommon 
in the out-patient practice of a children's hospital to hear the 
tale that the child has never been well since the measles. 
And this in all sorts of affections — marasmus, glandular ab- 
scesses, skin affections, etc. It is, however, very difficult to 
arrive at facts, but it is my belief that a very common result 
of measles is cheesy degeneration of the mediastinal glands, 
and a subsequent tuberculosis of the lungs. As I shall state 
elsewhere, one of the commonest forms of chest disease in 
childhood is this — a cheesy enlargement and softening of 
the mediastinal glands, and one or other form of lung disease 
supervening — generally a miliary tuberculosis, but not 
always. The history of many of these cases credits measles 
as the source, and nothing would seem to be more probable. 
Measles with its bronchitis or broncho-pneumonia is fol- 
lowed, no doubt, in most cases with more or less inflam- 
matory swelling of the corresponding .lymph glands, which, 
becoming choked with inflammatory products, undergo 
cheesy degeneration. Moreover, although less liable than 
scarlatina to any marked affection in the course of the fever, 
the glandulae concatenatse frequently undergo some slight 
enlargement and induration after measles, and no doubt 
slight changes originate then which, in unhealthy subjects, 



164 THE DISEASES OF CHILDREN. 

or from subsequent neglect, may run on into the' chronic 
enlargements, cold abscesses, scrofulous ulcers, etc., which 
are so well known and so much dreaded. 

Etiology. — Measles exhausts the soil, and, as a rule, oc- 
curs only once. But in some cases a second attack or re- 
lapse follows the first after a short interval ; in others a 
true second infection must occur, the second attack being 
many years after the first. Sucklings appear to be less 
liable to infection than older children, and when attacked 
often have the disease in a mild form. Measles is highly 
contagious in the catarrhal or pre-eruptive, and also in the 
eruptive, stage. After this it would appear that the infective 
power becomes much less active and soon disappears. But 
there are cases on record of infection being conveyed in the 
third week after the outbreak of the eruption, and therefore 
the rule to be pursued is that if possible a month should be 
allowed to pass from the onset of the eruption before a child 
is again permitted to mix with healthy children. It is prob- 
able, however, that very little risk indeed is run at the end 
of the third week, provided that the child is not surrounded 
by a more recently infected atmosphere, or by clothing im- 
properly disinfected. Measles is chiefly conveyed directly 
from the sick to the healthy ; but it can be, and is some- 
times, carried through the medium of healthy persons by 
fomites in the clothing. Such cases, however, usually show 
cause for copious infection — the medium being either a child 
coming from an infected house, or somebody who has re- 
cently been in contact with the sick. 

As regards isolation in a family, this is not usually prac- 
ticable in any strict fashion, but it should certainly be car- 
ried out for healthy children under four years of age, or for 
delicate children. In healthy children above that age, seeing 
that the disease so usually runs a favorable course, it is a 
question whether vigorous measures are worth attempting. 



MEASLES. I65 

Moreover, of isolation let it be remembered that to be ef- 
fectual it must be put into practice early, not when the erup- 
tion appears, but at the very onset of the catarrhal stage. 
This can best be done by the methodical use of the ther- 
mometer for every child that has been exposed to infection. 

Morbid Aanatomy. — Nothing is yet known for certain as 
regards the state of the blood. Quite recently a bacillus has 
been found in the urine of patients suffering from measles, 
but at present, though everything points towards future 
advances in this direction, nothing can be stated with cer- 
tainty. 

[Drs. J. M. Keating and Henry F. Formad, in an epi- 
demic of measles, occurring in the Children's Asylum of the 
Philadelphia Hospital during the early part of 1882, found 
micrococci in large numbers in the malignant cases both 
during life and after death, but none in cases of mild type. 
They were found in the liquor sanguinis, and in the white 
blood-corpuscles, acting especially upon the latter.] 

Drs. Braidwood and Vacher describe minute bodies ob- 
tained from the breath, and also in the skin, lungs, liver, 
etc., after death.* 

The microscopic appearances consist chiefly of more or 
less injection, perhaps even superficial erosion about the 
palate and epiglottis, sometimes also of the intestine ; and 
a diffused broncho-pneumonia. This has no special pattern, 
and need not be described here, as it is treated in its place 
as one of the diseases of the chest. Atelectasis is not un- 
common, and pleurisy is often associated with the pneu- 
monia. As less common complications, membranous 
laryngitis, diphtheria of pharynx or conjunctiva, keratitis 
and colitis, have occasionally been found. As a later con- 
dition Henoch describes a chronic broncho-pneumonia with 
dilated bronchial tubes and terminal abscesses in the lungs ; 



* Trans. Path. Soc. of Lond., vol. xxix., p. 422. 



1 66 THE DISEASES OF CHILDREN. 

but I am not clear that this can be separated from the far 
more common condition of cheesy degeneration of the 
bronchial glands and lung with miliary tuberculosis super- 
added. Some authors describe an acute fatty degeneration 
of the liver, but this is a change which is not peculiar to 
measles. 

[In the previously mentioned epidemic at the Philadel- 
phia Hospital, death was found to be due to heart-clot, the 
formation of which was supposed to depend upon the pres- 
ence of large masses of micrococci in and about the white 
blood-corpuscles.] 

Diagnosis. — The cardinal points in the diagnosis of 
measles are the slow onset and the coryzal aspect. In 
scarlatina, from which the difficulties chiefly emanate, the 
child is taken suddenly ill, often with vomiting, and within 
twenty-four hours the eruption appears. In measles there 
is less often sickness, and the rash does not make its appear- 
ance for four days. Of the eruption it is less easy to speak 
dogmatically — it is true that in a typical case the distinctions 
are plain, perhaps in few diseases more so — but there are 
many cases where from the eruption alone an opinion is 
impossible. 

For instance, a child, seven months old, was brought 
with what was clearly measles — coryza of two or three days 
and a characteristic swelling of the eyes. The eruption is 
thus described : there is a general red blush of the skin of 
the entire body, with additional raised small bright red 
papules, running sometimes in a crescentic pattern. The rash 
has some of the characters of scarlatina, some of measles. 
There will come to every one cases in which it is impossible to 
speak with certainty. In such it is necessary to take note of 
all the features of the case, and to form an opinion only after 
due deliberation — in the meantime taking all proper precau- 
tions. No discredit can attach to indecision when a decision 



MEASLES. 



167 



is an impossibility ; and, on the contrary, nothing can be 
more damaging to the reputation than an ignominious re- 
treat from a hasty diagnosis of " rose rash," or " German 
measles," before the developed and cold logic of facts. 

Treatment. — In the prodromal stage the child should be 
kept in one room in a regulated atmosphere of a tempera- 
ture of about 65 °. As the cough becomes more trouble- 
some, some sedative, such as the compound tincture of 
camphor, may be given — twenty or thirty drops every three 
or four hours for a child of four or five years. The diet 
should consist of plenty of milk and water or barley-water, 
with any farinaceous food that may be fancied, and bread 
and butter or toast. When the rash appears the child is to 
be kept in bed, and in an ordinary case very little more is 
required. If the skin itches, as it sometimes will, the body 
may be oiled three or four times a day with carbolic oil 
(1 +40). If the temperature rise to 103 , a warm bath 
98 to ioo° may be given as often as necessary. This acts 
as a good soporific in many cases. The cough is to be 
treated by small doses of the compound tincture of camphor 
or some such expectorant as F. 35. 

If these means are not sufficient, nothing relieves the 
hoarse hard cough of measles, which appears to be depen- 
dent upon an inflammatory condition of the rima glottidis, 
better than swabbing the fauces and throat with glycerine, 
or borax and glycerine, by means of a laryngeal brush. 

At the height of the eruption, the temperature not un- 
commonly runs up to 104 or 105 ° for a few hours, without 
any corresponding severity of the other symptoms. There is 
no need to interfere for a temporary disturbance of this sort, 
but for a persistently high temperature of twelve hours or 
more bathing should be resorted to. The first bath may be 
at a temperature of 95 ° to 98 . The temperature will often 
fall and sleep come by this means alone. If this fail to 



1 63 THE DISEASES OF CHILDREN. 

reduce the temperature, tepid or cold sponging may next 
be resorted to, or the chest and abdomen may be covered 
with an ice pack or by frequent cold compresses. As a last 
resort the tepid or cold bath must be tried. The child 
should be undressed as quickly as possible, so as to be 
worried as little as possible, and then immersed in a bath of 
the temperature of 90° which then may be rapidly cooled 
by the addition of cold water to So . Five or six minutes' 
immersion is usually sufficient. The child is then dried 
rapidly by a soft towel, and put to bed again between sheets. 
It is now to be watched carefully and the temperature 
recorded every two or three hours. The effect of the bath 
is sometimes very powerful, and the child remains livid- 
looking and collapsed for some time. In such cases small 
doses of brandy must be administered in warm milk at fre- 
quent intervals, and a hot bottle kept to the feet. Some go 
so far as to say that when the temperature reaches 102 , 
some one or other of these means are to be resorted to. 
Such a rule as this seems to me to be a meddlesome practice 
which, to say the least of it, is unnecessary. There may be 
cases in which, with a temperature of I02 c , the child is very 
ill, and the fever may be judged to be more than usually 
detrimental. For such, a bath, either tepid or cold, or cold 
sponging, maybe recommended; but for one such case, 
there are many others which run a perfectly favorable 
course, with a temperature even higher than this, and in 
which it may reasonably be asked in what way anti-pyretic 
applications could have bettered them. Each case must be 
judged upon its merits. 

[Should the fever be very high, sulphate of quinia by the 
mouth or better by the rectum, in two to four grain supposi- 
tories every three or four hours, will frequently reduce the 
temperature and, should there be much restlessness, produce 
sleep. At the same time should symptoms of exhaustion 



MEASLES. 



169 



or heart failure appear, tincture of digitalis or carbonate 
of ammonium with some alcoholic stimulant are indicated. 
The latter especially may be given freely when the case is 
malignant.] 

As regards staying in bed, measles varies so much that 
no rule can be laid down. It is generally well to keep a 
child in bed for a couple of days after the temperature 
becomes normal, and to its room for a week further. It 
should be kept indoors for three weeks or a month. The 
room occupied by a child with measles is to be kept well 
ventilated. In most cases the window may be allowed to 
be a little open at the top ; all draughts are to be avoided, 
and in obtaining fresh air the temperature of the room must 
not be allowed to fall. 

Broncho-pneumonia, if it exist, must be treated as in 
other cases. If the child be feeble, a few drops of sal vola- 
tile or a grain of carbonate of ammonium may be given, 
and some liquid extract of liquorice; or expectorants, such 
as squill, ipecacuanha, and compound tincture of camphor 
may be necessary. Counter-irritation may be applied by 
mustard-leaf for a few minutes over the diseased part, fol- 
lowed by a warm fomentation or warm linseed-meal poul- 
tice at first, and then a cotton-wool jacket. The diarrhoea 
that sometimes accompanies measles is probably due to 
some catarrhal state of the gastro-intestinal mucous mem- 
brane, and the first thing to be attended to therefore is the 
quantity of food that is being taken. The milk may be too 
much, and thin broth or cream and whey, or egg albumen, 
may suit better for a few hours. In severe diarrhoea cold 
compresses are very useful. Several folds of linen are to 

I be wrung out of cold water, put over the abdomen and 
covered with flannel, and changed every two or three hours. 
For medicines, thirty drops of brandy with some syrup and 
cinnamon water is a simple and an effectual remedy repeated 






170 THE DISEASES OF CHILDREN. 

every 'three or four hours. A teaspoonful of fluid magnesia 
is a good thing to commence with, given two or three :: 
a day, and subsequently, if not successful, a few drops of 
dilute sulphuric acid may be given with a drop or so of 
opium. Dover's powder is also useful for such cases, and 
so also are the liquor bismuthi and the subnitrate of 
muth. 

Membranous laryngitis will require a treatment such as 
that indicated in its special section ; but it may be said here 
that probably much may be done in measles to avert its 
onset if the throat and fauces be painted energetically with 
a solution of boracic acid, or borax and glycerine, every 
hour or two, whenever the cough becomes at all croupy in 
character. 

Other parts require also careful attention. The ophthal- 
mia which often succeeds to measles needs cleanliness and 
some mild antiseptic wash — permanganate of potassium being 
one of the best. The ear is prone to discharge after meas 
if so, it is at once to be taken in hand and treated carefully 
and regularly on antiseptic principles. It is to be gently 
syringed with a weak spirit lotion, a teaspoonful of spirits of 
wine to the half-tumbler of water, and carbolic oil (1 + 40), 
glycerine and borax, or the solution of boracic acid in gly- 
cerine, dropped in afterwards, and a little salicylic wool 
placed in the orifice. This is to be done three times a day, 
and every effort made to keep the part sweet. The great 
danger of aural discharge is its liability to decomposition, 
and decomposition of the discharge leads to extension of the 
inflammation to the bone which limits the tympanic ca 
and so to necrosis and its consequent evils. 

For some weeks after measles the health demands extra 
watchfulness. A salt-water bath should be given in the 
morning, and the clothing be always warm. Anaemia must 
be treated by iron and cod-liver oil. Any capriciousness of 



MEASLES. 



171 



appetite should be guided, if possible, back to normal by the 
same means, or by the judicious administration of stimu- 
lants, and above all by change of air — a dry, bracing air — 
whether it be sea or inland, and plenty of it, is one of the 
best restoratives. If there be any tendency to enlargement 
of the glands, no doubt sea air is the better ; otherwise I am 
inclined to think that a farm-house life, with its freedom from 
restraint, its good milk and bread, its rough-and-tumble 
exercise on a farm-pony, is the best restorative in existence. 






172 THE DISEASES OF CHILDREN. 



CHAPTER XL 

SCARLATINA. 

Of all the diseases of childhood there is none which pre- 
sents greater varieties of aspect than scarlatina — none which 
so often brings, with very short notice, unexpected deaths 
into a healthy household, or which more often selects for its 
victims the robust and healthy. Thus writes the late Dr. 
Hillier; and it would be difficult to put more shortly and 
more graphically the terrors of this .scourge. Some years 
ago, when taking charge of a practice in the country, I was 
called to a village some miles away to see a child who was 
very ill. I found a well-nourished girl of about five years 
old. She was pulseless, livid, and comatose, with an almost 
petechial scarlatinal eruption covering the skin. I was told 
that she had been quite well till the preceding afternoon. 
She had suddenly vomited while at the Sunday-school, and 
came home ill. I saw her about eight p.m. the next day, 
and she died within three or four hours ; so that the duration 
of the disqase from its outbreak to the death of the child 
was under thirty-six hours. 

Scarlatina is in great measure a disease of childhood, 
sixty-three per cent, of the deaths, according to Dr. Murchi- 
son, being under five years of age ; ninety per cent, under 
ten ; and ninety-five under fifteen years. The disease is not 
prone to attack children in the first year of life, and this is 
more markedly the case even than with measles ; but it may 
occur at any age, and cases are on record where infants have 
been born with the eruption upon them, and in which des- 
quamation has occurred in due course. Meigs and Pepper 



SCARLATINA. 1 73 

have seen it perfectly well-marked in an infant twenty-one 
days old. It is a disease which occurs in epidemics, though 
no large town is ever quite free, and it varies much in 
severity. Epidemics differ from each other in this respect, 
and case from case. To be infected from a mild form is no 
guarantee of an equally mild attack, etc. It is a disease 
which spreads by infection, though it is often difficult to fix 
the source of contagion. 

Incubation. — This is somewhat variable. It may be only 
a few hours — in many cases it is stated not to exceed forty- 
eight hours, and it rarely exceeds seven days. Conse- 
quently any one who has been exposed to the poison of 
scarlet fever, and who does not sicken within a week of 
quarantine, maybe pronounced safe. The disease is gener- 
ally latent at this stage, and the child retains its ordinary 
health. 

Prodromal Stage is short ; so much so that it is common 
to find a child quite well, or apparently so, till it suddenly 
turns pale and vomits ; and from that time onwards it is 
seriously ill, its extremities perhaps cold, fever high, and its 
whole aspect one of dulness and exhaustion. The disease 
may set in with convulsions or bad headache, but this is not 
common. More often there is some soreness of throat for 
a day or two before the child regularly sickens. 

Eruptive Stage. — Within a very few hours of the initial 
symptoms, during which the child will be more or less heavy 
and prostrate, and in high fever — perhaps vomiting fre- 
quently, perhaps with bad headache, perhaps convulsed — 
the eruption appears. It is seldom delayed beyond twenty- 
four hours. The rash consists of a general rosy blush upon 
which are set darker red points, the surface being smooth 
unless, as often happens, it is accompanied by miliaria. 
Some authors state that the dark red points in the eruption 
are sometimes distinctly raised. In case the roseola is not 

15 



174 THE DISEASES OF CHILDREN. 

too diffuse, the healthy colored skin peeps out here and 
there. The puncta may be even petechial in places. The 
rash appears first about the neck and shoulders, and rapidly 
spreads over the trunk and extremities. It is not always 
evenly diffused ; on the contrary, it is sometines so patchy 
as to create a doubt about the diagnosis. For instance, I 
have seen it almost confined to the buttocks, the back or 
the ankles. The face is said by some authors not to be 
often affected, but this is not strictly correct. There is not 
the punctate rash seen in other parts, but a diffused blush 
is by no means uncommon. The rash is accompanied by 
some swelling of the skin. The outbreak of the eruption is 
attended with a still rising temperature, with increased sore- 
ness of throat, and with a very rapid pulse. The extreme 
rapidity of pulse is indeed one of the characteristics of 
scarlatina, and it goes for little as an indication of the gravity 
of the case. A pulse of 160 is no uncommon feature. The 
sore throat is due to some swelling of the tonsils, but more 
especially to a general swelling and vivid redness of the 
whole mucous membrane. The tonsils, uvula, and palate 
generally are highly injected and swollen. The tonsils are 
covered with secretion of puriform appearance, and are more 
or less ulcerated after the third or fourth day. The tongue 
at the same time is thickly furred with a white or creamy 
fur, through which peep brightly red swollen papillae. The 
edges of the tongue are often free from fur, and are brightly 
red, the papillae being bulbous-looking from swelling. This 
constitutes the " strawberry tongue." The fur gradually 
cleans away as the disease subsides, and leaves an unnatu- 
rally raw red-looking tongue. In severe cases the throat is 
badly ulcerated, or shows patches of membrane upon it. 
The lymphatic glands in the submaxillary region are en- 
larged — in mild cases moderately, in bad cases much. At 
this stage the urine should be free from albumen. It is 



SCARLATINA. 



175 



usually somewhat scanty with diminished chlorides, and 
later with diminished phosphates. It may give evidence of 
a trace of blood by the guaiacum test, and there may even 
be albumen or casts. 

The temperature may rise to any height between 102 
and 105 °, and it remains high for three or four days. It 
gradually subsides as the rash disappears, and if no compli- 
cations arise, becomes normal in seven or eight days. It is 
often hindered in its descent, however, by a disproportionate 
severity of the disease of the fauces — ulceration of the 
mucous membrane, or swelling of the lymphatic glands — 
and many young children pass into a condition not easily 
described, in which the temperature remains high, with a 
raw, red condition of the mucous membrane of the mouth, 
a dry skin and general debility lasting for many days. 

At the end of a few days, desquamation begins. In nine- 
teen cases noted by Hillier, its commencement varied from 
the sixth to the twenty-fifth day. The skin, having remained 
harsh and dry meanwhile, now becomes covered with small 
branny scales, while about the palms of the hands and soles 
of the feet larger scales are detected. Occasionally in these 
parts the entire epidermis is shed en masse as a glove, the 
nails, perchance, coming off also. The natural duration of 
the desquamating stage is well-nigh unlimited — the scales 
being like the dead leaf or blade of grass which depends 
upon external forces for its removal — but it is advisable to 
determine it as quickly as possible, and this may be easily 
done by the frequent repetition of warm baths, scrubbing, 
and frequent oiling. 

Modifications. — Such, shortly stated, is typical scarlatina. 
But this is hardly sufficient — it is necessary again to remind 
the student that there is no disease which deviates more from 
a type than this does. The time-honored description of 
three forms — the simple, anginal, and malignant — testifies to 



1/6 THE DISEASES OF CHILDREN. 

this. I shall adopt no such' subdivision, for the simple 
reason that there are so many varieties or degrees of severity 
which pass as such, that it is less perplexing to the student 
to follow existing authors in stating, generally, that some- 
times it is so mild that the illness is hardly appreciable, and 
there is either no eruption or it is of the very slightest 
amount; sometimes the eruption fades in a day or two in 
place of lasting five or six days. Again, the intensity of 
the disease in the throat varies much. It may be very little ; 
it may, on the other hand, be attended with extensive ulcer- 
ation and even the formation of membrane.. At another 
time the fauces may at the most not indicate any severe 
affection, while yet ulceration is insidious, progressive, and 
ultimately extensive. As regards the disease in the throat, 
it is the most regular in its appearance of all the symptoms ; 
it is certainly often present when scarlatina is rife without 
any other symptom, and patients thus lightly affected are 
for the most part protected from subsequent infection. And 
as regards young children, it is well to remember that it may 
be present to a considerable extent and pass unnoticed, the 
refusal to take food which indicates its existence being at- 
tributed to the anorexia of the febrile state. The enlarge- 
ment of the lymphatic glands at the angle of the jaw is the 
best evidence of its presence and its extent, and whenever 
there is any swelling at the angle of the jaw, a careful exam- 
ination of the fauces should be made. 

With reference to the question of malignancy, scarlatina is 
a disease which, like small-pox, is sometimes so destructive 
that its entrance into the system is sufficient to put a stop 
to all the natural processes, and to bring about coma, col- 
lapse, and death within a few hours. In cases such as this, 
as already narrated, the child vomits, the temperature runs 
up to perhaps 105 °, the pulse becomes very rapid and feeble; 



SCARLATINA. \JJ 

the extremities become cold, the face lividly pale, and there 
is often profuse sweating. 

In a less rapidly fatal and more prevalent form, the fever 
runs on for four or five days with delirium, perhaps vomiting, 
and the child succumbs, exhausted, with dry tongue, pos- 
sibly stupor, convulsions and coma, towards the end of the 
first week. 

Complications. — Strictly speaking there are not many. 
The ulceration of the fauces may be extensive and lead to 
hemorrhage, or to the rapid formation of glandular ab- 
scesses, or even to sloughing of the skin. The inflammation 
of the fauces sometimes extends to the larynx, as in diph- 
theria. Then again convulsions may suddenly set in, 
generally in association with the sudden onset of albumi- 
nuria, but sometimes they may be associated with the onset 
of meningitis, which is, however, a rare complication, or with 
the commencement of some intercurrent inflammation. 
Sometimes in severe cases, as already noticed, there ensues 
a condition' of coma and rapidly fatal collapse. Diarrhoea 
is sometimes troublesome ; occasionally, too, the joint affec- 
tion known as scarlatinal rheumatism may set in early, and 
may be associated with endo- and more rarely with peri- 
carditis, and it may be that in severe cases the synovitis may 
be of a destructive form, and the joint rapidly fill with pus, 
or thin purulent fluid. Scarlatina may be associated with 
other exanthems and fevers. I have seen the eruptions of 
varicella and scarlatina both out at the same time. Dr. Gee 
has seen the same. Diphtheria or typhoid fever may either 
of them run concurrently with it — it has usually been that 
scarlatina has occurred in the course of typhoid fever — and 
both measles and small-pox are occasionally superadded to 
scarlet fever. The supervention of diphtheria is very likely 
to be fatal, but measles and varicella neither alter their 



1/8 THE DISEASES OF CHILDREN. 

course, nor that of the scarlatina, nor do they necessarily 
increase the gravity of the prognosis. 

And here may be mentioned what has been called surgi- 
cal scarlatina. It has been noticed by many observers that 
a red scarlatina-like rash sometimes appears after operations, 
the nature of which has seemed doubtful from its quick ap- 
pearance within a day or two of the operation, and the modi- 
fied course which it often runs — chiefly in the direction of 
mildness and rapid subsidence. From what has already 
been said on the incubation of scarlatina, these w r ill seem but 
hazardous distinctions with which to combat the scarlatinal 
nature of this affection; and there is now no longer any 
doubt that it is true scarlatina for the following reasons, 
which are admirably stated by Dr. Gee : That it occurs in 
epidemics ; that a severe case (with bad sore throat and even 
albuminuria) occasionally relieves the monotony of the mild 
form ; that the disease is not exclusively confined to patients 
who have been subjected to operation ; and lastly, that how- 
ever freely these patients are subject to scarlet fever con- 
tagion afterwards, they do not contract the disease. It might 
be thought that an operation or open sore would naturally 
render its subject more liable to develop a disease which is 
propagated by fomites, since erysipelas is known to attack 
such cases with peculiar readiness, and probably enters by 
the wound. But from some observations made by Dr. Paley 
and myself at the Evelina Hospital, it appears probable that 
the poison does not gain an entrance by this means ; for the 
antiseptic treatment of wounds, a most effective bar to the 
occurrence of erysipelas, is none to the advent of scarlatina. 
Several interesting hypotheses have been advanced to ex- 
plain the readiness with which operation cases develop 
scarlatina. Sir James Paget attributes it to the lessened 
resistance induced by the surgical operation. It appears to 
me, however, that being by no means confined to the sub- 



SCARLATINA. 1/9 

jects of recent operations, the more probable explanation is 
that some modified process of incubation takes place in any- 
inflammatory focus that may be existent. This, however, 
is not the place to discuss a question of such a kind — the 
important point for the student to lay hold of is, that surgi- 
cal scarlatina is true scarlatina, however modified, and must 
be dealt with as such. 

Relapses are not very rare. Hillier mentions the case of a 
student who had had three attacks of scarlatina, and a week 
after his third attack he had a distinct relapse. Thomas de- 
scribes pseudo-relapses in which a roseolous eruption breaks 
out after the fever has run its course. They generally ter- 
minate favorably. 

A second attack of scarlatina in the same individual is 
much more common. Indeed, of all the exanthemata, scar- 
latina is the one which is least protective against its recur- 
rence. The large majority of persons are exempt, however, 
from any typical recurrence, but when scarlatina is prevalent, 
sore throats are common even in those who have suffered 
from the disease at some former time. 

Sequel88 are numerous. They are — nephritis, leading to 
albuminuria and dropsy; dropsy without albuminuria, con- 
vulsions, serous inflammations, glandular abscesses, diph- 
theria, otorrhoea, rheumatism, etc. 

Scarlatinal dropsy, always understood to mean nephritis 
and albuminuria, may occur at any time, and should always 
be watched for throughout the attack. It most usually 
begins during the desquamative stage, but it may begin in 
the eruptive. If the urine be carefully tested, a transient al- 
buminuria, or the presence of blood, is probably not uncom- 
mon in the first week of scarlatina, and I have seen, as 
probably most of us have, a severe nephritis begin suddenly 
as early as the fifth day. As a rule, however, the stage of 
desquamation is the time for albuminuria, and the urine 



ISO THE DISEASES OF CHILDREN. 

should be carefully tested day by day until this stage is com- 
pleted. The frequency of albuminuria appears to vary in 
different epidemics. Some practitioners may be found who 
have but seldom come across it, and who indulge in the be- 
lief that it results from neglect or bad treatment. This is 
not correct. There can be no doubt whatever that the ma- 
teries morbi of scarlatina is particularly obnoxious to the 
kidneys. In the early days of the fever the urine will often 
reveal by excess of mucus, epithelium, hyaline casts, and 
occasionally by blood and transient albuminuria, distinct 
evidence of renal disturbance; children, too, become dropsi- 
cal and albuminuric while yet in their beds, and with the 
eruption still out upon them. Nevertheless, this is a whole- 
some belief, as it makes for what is a powerful prophylactic 
treatment, and there can be no doubt that much less would 
be heard of scarlatinal dropsy were children dieted more 
strictly, and confined during convalescence more rigorously 
to bed, or to their room, than has often been the custom 
hitherto. The albuminuria varies so much in duration, ac- 
cording to the severity of the nephritis that occasions it, that 
it is impossible to speak in any precise way of its course. 
In mild cases it may last only a few days, the albumen never 
being in large quantity. If there be much albumen and 
blood, then there is severe disease of the kidney, and its 
course will be such as an acute nephritis is known to take — 
a lingering one, lasting perhaps a month or six weeks, and 
often much longer. Nevertheless, it does occasionally hap- 
pen that a considerable quantity of blood or albumen appears 
quite suddenly, and disappears in the course of a day or two, 
almost as suddenly. It is said most commonly to set in 
towards the end of the second week ; but so long as desqua- 
mation lasts, an uncertain period of some weeks, there is a 
chance of its recurrence. In thirty-four of my own cases, 
of which I have notes, it set in — in the first week in two, in 



SCARLATINA. I 8 1 

the second in eight, in the third in seven, in the fourth in 
nine, at some later period in four, and in four the relation to 
the eruption was uncertain. It usually sets in with fever, 
perhaps with vomiting, and the pallor which comes over the 
child's face is often most striking. In the cases which I have 
seen the pulse has not presented those characters of resist- 
ance or hardness which are recognized so quickly in adults. 
It is stated to become preternaturally slow, fifty to sixty. It 
is more common to find it irregular. The evidence of car- 
diac disturbance is indeed often striking. The impulse is 
displaced outwards, and may be felt sometimes at one spot, 
sometimes at another. The beats are irregular in their force, 
and halting in time; the first sound may be thick and mur- 
murous, or accompanied by a distinct systolic apex bruit, 
and the second sound is accentuated. Twelve cases out of 
thirty-four gave evidence of heart disturbance such as this, 
and in six of the twelve there was a distinct bruit. The urine 
quickly presents characteristic appearances; it becomes 
scanty, is passed frequently in small quantities, and is either 
smoky or deposits a dirty-brown sediment, or may be port- 
wine colored from the presence of pure blood in quantity. 
It is usually highly albuminous, and shows blood, large epi- 
thelial and hyaline casts, and much granular detritus under 
the microscope ; but there is much variation in this respect. 
In the less acute cases the albumen may be in moderate 
quantity, the color but little removed from a normal standard, 
and urates present in considerable quantity. The dropsy of 
the face, and in severe cases of the subcutaneous tissue 
generally, is prone to follow quickly, and seemingly often 
suddenly. When the disease runs a favorable course, the 
albumen may remain in the urine in good quantity for four 
or five days ; but it quickly diminishes, the blood disappears, 
the urine increases in quantity, urates begin to be passed in 
quantity, and gradually all the symptoms disappear. 

16 



1 82 THE DISEASES OF CHILDREN 

Unfortunately there are many other less favorable results. 
The disease may set in with convulsions, or the urine may 
become gradually more scanty, the dropsy more extreme, 
and convulsions supervene after four or five days or more. 
Convulsions are necessarily serious, and are often fatal ; but 
in many cases they subside, the child remains drowsy for a 
few days, and gradually comes round again. 

At another time a child will seem to be doing well, with 
but a moderate amount of dropsy and albuminuria, when 
somewhat suddenly its breath becomes short, coarse rales 
appear in all the bronchial tubes, and death follows quite 
rapidly, and even, not uncommonly, suddenly and unexpec- 
tedly. These are they who are said to die by acute oedema 
of the lung, but in some of whom at any rate acute dilata- 
tion of the ventricles of the heart takes place, and with this 
oedema of the lungs and sudden death. In other cases the 
serous cavities become full, in conjunction with extreme 
anasarca — a state of things more usually present in the 
more chronic cases. Ascites may be present at any time, 
and is not necessarily of serious omen in acute cases, pro- 
vided that the pleura and pericardium remain free. 

On the other hand, the nephritis may commence insidi- 
ously, without any of the symptoms indicative of acute 
disease, and of course therefore without anasarca. Such 
cases are, however, rare in comparison with scarlatinal 
dropsy. 

In hospital practice, yet another condition must be men- 
tioned as the most largely prevailing of all — viz., where 
children are brought for dropsy, many weeks after some 
indefinite attack of illness which we can only suppose has 
been scarlatina. In these cases also the onset of the renal 
affection is probably insidious. No history can be given of 
any striking alterations in the character of the urine at any 
time, and with considerable albuminuria there is usually 



SCARLATINA. 



183 



free diuresis and little alteration of the color of the urine. 
In these cases the prognosis must be cautious. 

[A retrospective diagnosis is often possible in these cases 
from the peculiar appearance of the fingers and toes. Des- 
quamation continues here long after it has ceased in other 
parts of the body, and they present a smooth and shiny 
surface, as if smeared with oil.] 

Dropsy without Albuminuria, — Meigs and Pepper state 
that they have never met with dropsy after scarlatina in 
which they did not find albuminuria. Most writers, how- 
ever, allude to a condition of what, for the sake of dis- 
tinguishing it, we may call simple anasarca, and it is not 
uncommon. 

The first case that came under my own notice was in the 
Evelina Hospital in 1869 — a boy of four, under Dr. Hilton 
Fagge. There was no history of scarlatina, but he had 
been suddenly attacked when in good health a fortnight 
before with frequently recurring vomiting. He had been 
dropsical for four days, and when admitted was suffering from 
general anasarca, ascites and some fluid in one pleura. The 
urine was 1007, and contained no albumen. The anasarca 
gradually disappeared without any albuminuria. Since then 
I have seen several less pronounced cases, mostly in the 
out-patient room, and within the last few weeks another 
extreme case has been under my care in the Evelina Hos- 
pital, of which the following are the notes : 

A girl, aged three and a half years; scarlatina two 
months ago ; ill a fortnight, but not kept in bed. Dropsy 
of the legs began a month ago. When admitted, the child 
was remarkably dropsical, the whole of the subcutaneous 
tissues being affected. The feet were blue and greatly 
swollen. She was in a collapsed condition. There was no 
desquamation. A small quantity of urine obtained con- 
tained no albumen. She was at once put into a wet pack. 



184 THE DISEASES OF CHILDRE . 

This produced no perspiration, and she passed very little 
urine. The first sound of the heart was reduplicated, and 
there was a slight apex murmur. The oedema rapidly sub- 
sided, and at the end of three weeks had entirely disap- 
peared. The urine was repeatedly examined, and, though 
scanty for the first two days, it never contained any albumen, 
nor any abnormal microscopical elements. The tempera- 
ture was normal throughout. The treatment consisted of a 
milk diet, the wet pack, and an occasional jalap purge. 
Subsequently perchloride of iron was given for the anaemia. 

Steiner* writes of this affection thus : " Frerichs has de- 
scribed a rare form of dropsy, without any disease of the 
kidneys, occurring after scarlatina, which he believes to be 
due to paralysis of the cutaneous nerves by exposure to 
cold during desquamation, and I have lately seen one such 
case where repeated examination of the urine revealed no 
change, whilst there was very acute dropsy of the skin 
without any effusion into the cavities, which lasted twelve 
days." Thomasf alludes to epidemics in which all the 
dropsical patients were free from albuminuria. HillerJ sug- 
gests that the slight oedema, with which he alone has met, 
may be due to anaemia, which is often very great, and in- 
duced with great rapidity. Latterly, Dr. Duckworth has 
published a well-marked instance of this affection, and it 
seems not unlikely from this and other cases that the dropsy 
is related to suppression of the urine, which was a very 
marked feature of my own case and also in that published 
by Dr. Duckworth.- 

[I have never met with this condition, although two cases 
of scarlatinal dropsy have occurred in my practice in which 
the urine though non-albuminous contained casts, and it 

* " Diseases of Children," Eng. ed., p. 341. 

f Ziemssen's " Cycl.," American ed., vol. ii., p. 259. 

J " Diseases of Children, p. 305. 



SCARLATINA. 



I8 5 



seems but just to insist that the absence of these elements 
should be proved by careful microscopic examination before 
declaring a dropsy following scarlatina to be independent of 
renal disease. 

At the same time, as suggested by Hillier, it is quite pos- 
sible to conceive that oedema may be due to anaemia in- 
duced by the fever. 

My cases presented the following histories : 

The first, a boy three and a half years old, had scarlet 
fever and died subsequently of meningitis. During the five 
months of his illness he had two attacks of desquamative 
nephritis. The first occurred, in spite of every precaution 
in regard to diet and exposure, three weeks after the onset 
of the fever, and subsided a month later. The other began 
one month afterwards, the urine being scanty and smoky 
with a specific gravity of 1030, on acid reaction, and con- 
taining a large quantity of albumen, numerous epithelial 
and blood-casts and many free blood-corpuscles. In two 
weeks the urine became more copious and commenced to 
clear up, and by the end of another fortnight it was passed 
in abundance, was perfectly clear and contained no albumen, 
but a few granular and hyaline casts. Subsequently on four 
separate occasions, at intervals of several days, the urine, 
which was normal in quantity, color, reaction and specific 
gravity, was carefully examined and found to be absolutely 
free from albumen, though the microscope revealed many 
hyaline and slightly granular casts. 

The second case, a boy five years of age, had scarlatina 
in February. The attack was so light that the child was not 
considered ill enough to be put in bed or to require a phy- 
sician. When first seen in March the hands and feet were 
still desquamating, there was considerable anasarca and a 
clear history of a precedent scarlet rash and fever. The 
urine was diminished in quantity, acid, dark-colored, de- 



1 86 THE DISEASES OF CHILDREN. 

posited a soot-like material on standing, and contained a 
quantity of albumen and numerous epithelial, granular and 
hyaline casts. 

He improved rapidly under treatment, and three weeks 
later the dropsy had nearly disappeared. The urine con- 
tained a few hyaline-casts but no albumen. Then there was 
a slight return of renal congestion indicated by the reap- 
pearance of the soot-like deposit and a small amount of 
albumen. After four days the urine was again clear and 
free from albumen, but a few hyaline casts were discovered. 

During the next four weeks, as the feet were occasionally 
cedematous, the urine was examined repeatedly and found to 
contain hyaline casts though it was non-albuminous.] 

Serous inflammations are not uncommon after scarlatina, 
and they are liable to be of a suppurative form. Empyema 
is the most common, but suppurative pericarditis and peri- 
tonitis have both been known to occur. Endocarditis, 
meningitis, and inflammation of the joints must also be 
mentioned ; the two latter, however, cannot be dissociated 
from the rheumatic affection, which will be considered 
immediately. An acute empyema may possibly prove 
fatal ; the pus being often thin, rapidly formed, and attended 
with severe constitutional disturbance ; but as a general 
rule purulent effusions* do well. 

Glandular abscesses in the neck are very common. In 
young children they are apt to be associated with a diffuse 
inflammation of the cellular tissue of the neck, and some- 
times with extensive sloughing of the skin. In other cases 
there is a diffuse brawny infiltration of the tissues of the 
neck, rather than any definite glandular affection. In either 
case the complication is a serious one. When the abscess 
is circumscribed and confined to one gland or so, there is 
not necessarily any ground for alarm. 

* When large and obstinate thoracocentesis is necessary. — Ed. 



SCARLATINA. 



187 



Diphtheria has already been mentioned as a complication ; 
it is usually fatal as such, but it occasionally occurs later^ 
with equally disastrous issue, either by extending to the 
larynx or by the exhaustion of the recurrent fever. 

Otitis is very common. The inflammation may be lim- 
ited to the external passage, or spread up to the middle ear 
by the Eustachian tube from the disease in the pharynx. 
In the latter case particularly — and in any case, if the dis- 
charge is of long continuance — disease of the bone is apt 
to arise, and either permanent deafness or worse happens. 

Of late years scarlatinal rheumatism has been much 
talked about. It is a common sequela ; occurring some- 
times during the eruptive stage, it is more common to- 
wards the end of the second week or later. It is quite 
like acute rheumatism, as we know it in childhood, from 
other causes, and shows itself, sometimes by pains only, 
more or less manifest, sometimes by swelling of the larger 
joints. Steiner states that it affects the knee and elbow by 
preference, but I have more often seen the wrists and ankles 
affected. It is attended by pericarditis rarely ; by endocar- 
ditis commonly ; or rather it is frequently associated with a 
systolic murmur at the apex of the heart, but in many cases 
this bruit disappears. Probably about five per cent, of the 
cases of scarlatina develop a murmur, but the majority of 
such bruits disappear within a short time. The relation of 
this affection to acute rheumatism is still uncertain. Henoch 
discards the term rheumatism, and proposes that the affec- 
tion shall be called scarlatinal synovitis ; but I have seen 
several cases in which there was a strong family history of 
acute rheumatism — so often so that I have come to think 
that it may be a constitutional trait, appearing under circum- 
stances of deteriorated nutrition, rather than a special feature 
of the scarlatinal poison. 

It occasionally happens that this scarlatinal synovitis runs 



1 88 THE DISEASES OF CHILDREN. 

on to suppuration and destruction of the joint, with symp- 
toms of pyaemia. Such cases have, no doubt, tended to 
throw doubt upon other affections of the joints, it having 
been thought that the pyaemia of the one might be present 
in milder form in the serous inflammation of the other. But 
the suppurative inflammation is so rare that the two forms 
of joint disease may well be due to distinct causes. 

There are other sequelae which occur less often — such 
are pneumonia and bronchitis, chronic enlargement of the 
tonsils, wry neck (of which I have notes of two cases), chronic 
diarrhoea, etc. ; and, lastly, may be mentioned as not uncom- 
mon, a chronic inflammatory condition of the mucous mem- 
brane of the nose and mouth, in which the surface of the 
nose becomes excoriated, incrusted with dry crusts, and 
exudes a thin discharge, whilst the mouth is superficially 
ulcerated and dotted with thin membranous patches, as in 
other forms of stomatitis. 

Etiology. — It is a disease which spreads by infection, and 
is communicated by means of the exhalations and secretions, 
and also by the scurf from the desquamating skin. But 
little infectious, perhaps not at all so, during the stage of 
incubation, the risk rises during the eruptive, and reaches 
its height in the desquamative stage. Doubts have been 
expressed by many whether it may not arise de novo ; but, 
as it is endemic and widely spread, and is even not unknown 
in domesticated animals, such as horses, dogs, and cats, in 
no case can it be said that infection is impossible, and con- 
sequently there is but little use in discussing a question upon 
which doubt is dangerous. Further, the germs of scarlatina 
appear to retain their vitality for long periods, and cases are 
on record where a fresh outbreak of the disease has occurred 
months and even so long as a year after a former one, owing 
to the housing and subsequent use of improperly disinfected 
clothes, The poison can in this way be carried for long 



SCARLATINA. 



189 



distances by such things as letters or books, and in this 
respect it differs from measles and other exanthems ; but 
in direct contagion it appears to be less intense than that of 
either whooping-cough or measles. It can also be conveyed 
by articles of diet. Of late years outbreaks have been traced 
unmistakably to the contamination of milk. The poison has 
been shown to be effectually destroyed by exposure to a 
heat of 212 , from which it follows that all clothes, woollen 
or linen stuffs — everything, in fact, that can be so treated, 
that has been in contact with scarlatinal patients — must be 
subjected to a dry heat of at least 212 for some hours be- 
fore they can be considered to be disinfected. The poison 
is further possessed of extreme tenacity, and for this reason 
there is often great difficulty in efficiently disinfecting houses 
or rooms, and the fever breaks out again and again after what 
has seemed to be the most thorough disinfection. 

Upon these considerations depends the answer to the 
question, when may a child who has had scarlatina mix 
with other children? Not until desquamation is over, and 
six weeks is about the necessary quarantine, provided that 
the child has been carefully tended with reference to this 
matter. Desquamation will linger for two or three months, 
if not hastened by proper attention to the cleansing of the 
skin. I must confess, however, to thinking it advisable to 
act with perhaps exaggerated caution in such matters. It 
is often a question of sending a child back to school, where 
it comes into close contact with perhaps a large number of 
healthy children, and where contagion, if conveyed, will be 
most disastrous. It is much better in such a case, that the 
one child should suffer the, after all, but slight loss entailed 
by an extended holiday, than that any risk should be run 
by the many ; and I do not hesitate to extend such par- 
tial quarantine to two, yea, even in some cases, three months. 
The medical man has to certify to the clean bill, and upon 



I9O THE DISEASES OF CHILDREN. 

him lies all the responsibility. He need indeed be cautious, 
considering the facts which have been proved against it, 
when dealing with scarlatina. Ten days is sufficient iso- 
lation for a child who has been in contact with scarlatina, 
provided he and his clothes have been disinfected. 

Morbid Anatomy. — Of morbid changes there are none 
sufficiently constant to make them pathognomonic. Micro- 
cocci have been discovered in the blood, and it is probable 
that we are on the eve of more positive information in this 
direction. All the known facts point to a particulate con- 
tagium, although we cannot yet identify it. 

Of macroscopic changes we may expect to find, during 
the height of the fever, perhaps some mottling of the skin, 
oedema of the fauces, with livid congestion or ulceration ; 
perhaps suppuration of the tonsils. The lymphatic glands 
in the neck are swollen, as also may be the mesenteric 
glands and other glands of the body. The cervical glands 
may be suppurating, or in severe cases are imbedded in a 
diffuse oedema. Thomas alludes even to extravasation of 
blood around them as a result of intense inflammation. 
There is really nothing to note elsewhere. The bronchial 
tubes have been found injected, and the spleen is at times 
swollen, but this organ is by no means so frequently affected 
as in typhoid fever. 

Microscopically various changes have been found. Fen- 
wick has noted an infiltration of the rete mucosum with 
leucocytes ; and to some active processes of cell growth of 
this kind set up by the fever must be attributed the later 
symptom of desquamation. Klein has found that minute 
changes go on in the viscera, particularly in the kidney, 
spleen, liver, and lymphatic glands. Some of these — for 
example, the hyaline degeneration of the intima of the small 
arteries, and the parenchyma of the liver and kidney — may 
be no more than the conditions dependent upon the febrile 



SCARLATINA. 



I 9 I 



state, for they have been found by several observers in other 
pyrexial states than scarlatina ; but it is important to note 
that, in addition to these, Dr. Klein has found in the early 
days of scarlatina (within the first week), that there is a 
hyaline change in the Malpighian tufts ; that the epithelium 
of the capsule shows signs of disturbed function by prolifer- 
ation ; and that the muscle nuclei of the small arteries un- 
dergo similar changes. Further, w r hen the disease extends 
on to the tenth day, there then appears an extensive accu- 
mulation of leucocytes in the connective tissue around the 
vessels and tubes. Thus we have anatomical evidence, 
within the first week, of the action of the scarlatinal poison 
upon the kidney. The changes, indeed, are very similar 
in kind, to those that have been detected in the skin. The 
risk of nephritis is thus clearly indicated, and the warning 
given to take care of the kidney. In this stage there will 
be little or nothing morbid in the general appearances of 
this organ ; it may perhaps be over-full of blood, but no 
conclusion can be drawn from that. The later stages of 
scarlatinal nephritis show to the naked eye enlargement 
or swelling of the kidney, and with this increased resistance 
when handled or cut. The surface becomes mottled from 
the admixture of the natural color with patches of opaque 
yellow or buff, and, more closely examined, the surface is 
seen to be speckled with minute yellow dots, and the section 
is muddled from loss of the natural streaky arrangement of 
the alternating vascular and tubal areas. The amount of 
this yellow or buff material varies much, and with it the 
appearances of the kidney. When extreme the aspect will 
be that of the large white kidney, but, so far as I have seen, 
it is not often that such is the case. In children there may 
be very advanced changes in the kidney, with but little pro- 
nounced departure from the natural appearances. The kid- 
ney may be rather paler than natural ; perhaps a more buff 



192 THE DISEASES OF CHILDREN. 

tint, but as to which there would be a doubt had we no clin- 
ical evidence to go upon, and no microscopic examination 
to further us. Microscopically, however, the changes are 
fairly constant. There are the appearances of glomerular 
nephritis. These are such as have been enumerated above, 
but in addition, we find extravasation of blood or fibrinous 
material into the capsule, with mpre marked epithelial pro- 
liferation of the lining of the capsule and of the tuft itself; 
the tuft is either turgid with blood, or pressed back to one 
side of the capsule by the extravasation ; and there are hy- 
aline thickenings of the capsule, and peri-glomerular collec- 
tions of leucocytes. In addition to all these the renal 
tubules are choked with cloudy or fatty epithelium ; there 
are peri-vascular aggregations of inflammatory products in 
parts other than the capsules ; local patches of congestion 
with the vessels crowded with blood ; and casts in some or 
other of the tubes, composed sometimes of blood, sometimes 
of fibrinous material. It is the more or less of this change 
and of that, at one time or another, which makes up the 
variety of pattern and gives perplexity to the student, so 
that it is necessary to insist upon the fact that a very bad 
kidney may not reveal itself decisively to the naked eye. 

The morbid changes in the viscera associated with renal 
disease are not special to childhood, and need but a passing 
mention, with perhaps one exception — viz., dilatation of 
the heart. It is usual to find in death from scarlatinal dropsy 
that there is both ascites and hydrothorax, whilst the lungs 
are small, of a dull leaden hue — their bases being solid from 
an oedematous pneumonia, and the upper part also deficient 
in air — and with a copious frothy fluid exuding on pressure. 
This is the condition called acute oedema, a well-recognized 
condition towards the end of a case of chronic parenchym- 
atous nephritis. There is very likely to be double pleurisy 
in addition, perhaps pericarditis or endocarditis. But it has 



SCARLATINA. 1 93 

not been very generally recognized that the ventricles are 
liable to be dilated. Dilatation of the heart is recognized as 
an occasional result of the scarlatinal poison or of the fever 
engendered by it, but it is not this to which I am now 
alluding. It is more important to impress upon the student 
that ventricular dilatation is not uncommon as the result of 
scarlatinal nephritis. It is indeed, a common result of 
chronic nephritis in adults ; but, whilst adults probably but 
seldom die from acute dilatation of the heart in acute renal 
disease, children are liable to die quite suddenly. In this, 
perhaps, may be found the explanation of a difference which, 
as I believe, exists in renal disease between the pulse of 
children and adults. The hard pulse of chronic renal dis- 
ease in adults is well recognized, and obviously it is the 
combined result of two factors — obstruction in the capillaries 
or small arteries, and compensatory muscular action on the 
part of the heart. The power of cardiac compensation is 
most striking in adults ; as it is less evident in childhood ; 
and therefore acute dilatation of the heart must be watched 
for and guarded against. I have once seen diffuse suppu- 
ration in the wall of the heart in scarlatinal nephritis. It 
occurred in a girl of three and a-half years, thirty-one days 
after the onset of the fever.* Such a case is perhaps of 
more value in emphasizing the tendency that exists in scar- 
latina and its sequelae to changes in the muscular wall of 
the heart, than in itself it would otherwise be. A rare occur- 
rence of this kind can be the experience of but few. 

To dilatation of the heart must also be attributed some of 
the cases of hemiplegia which occur after scarlatina ; but, 
these being common, most writers mention their occur- 
rence ; and, whilst some cases are due, no doubt, to dis- 
lodgement of clots from the inflamed valves, some may be 

* " Path. Soc. Trans.," vol. xxxL, p. 70. 



194 THE DISEASES OF CHILDREN. 

due to the formation of thrombi in the trabecular pouches of 
a dilated ventricle. 

Of other morbid changes which are more or less prone 
to associate themselves with the post-scarlatinal state, there 
must be mentioned empyema, suppurative peritonitis, sup- 
puration in one or other of the joints, suppuration in the 
middle ear with disease of the petrous portion of the tem- 
poral bone, periostitis and necrosis of the long bones, 
sloughing of the glands of the neck and the superficial skin, 
cancrum oris and broncho-pneumonia. Even this list 
might be extended, but without any great advantage, for all 
these are but occasional occurrences, although, when scar- 
latina claims so many victims during the year, they can 
hardly be said to be uncommon. 

Diagnosis. — When in doubt, admit it, and act on the as- 
sumption that the disease is scarlatina. Rotheln, roseola, 
bastard measles, German measles, and all such terms are of 
bad reputation, and are only to be admitted when the evi- 
dence is indisputable that the attack is not scarlatina. There 
may often be a doubt, but the public is to have the benefit, 
not the eruption. Scarlatina may be mistaken for measles 
when the latter is more diffused and less raised than usual, 
or when the scarlatina is less diffused and more livid than 
usual ; a scarlatina-like rash sometimes precedes the erup- 
tions both of measles and variola — the latter by no means 
uncommonly, but variola is hardly one of the diseases of 
children. The lividity and elevation of the spots are to be 
attended to in addition to the coryza which is so character- 
istic. 

Rotheln is characterized by the rash which is sometimes 
more like scarlatina, at another like that of measles. At 
one time there is much coryza and angina, at another none ; 
and of individual cases it may be impossible to speak de- 
cidedly. But it occurs in epidemics, runs a short, sharp 



SCARLATINA. 



195 



course, without much illness, without desquamation, and 
without sequelae. 

Tonsillitis is usually one-sided, and limited to the tonsil. 
The glands at the angle of the jaw are all but quiescent. 
There is no preceding vomiting, the attack is sporadic, 
acute upon some chronic enlargement, and is not very com- 
mon in childhood. Roseola, if it can be distinguished, is of 
a lighter tint ; less papular-looking, may be traced to food 
or drink, etc. Dr. Gee mentions that the swelling of the 
joints which sometimes occurs in scarlatina before the out- 
break of the eruption had been mistaken for rheumatism. 

Prognosis. — An attack ushered in by convulsions is nearly 
always fatal, and severe delirium is also a symptom of great 
gravity. Other symptoms of bad omen are excessive py- 
rexia, nasal discharge, evidences of failing circulation — 
lividity of the surface, excessive rapidity and feebleness of 
the pulse — diarrhoea, and any tendency to exhaustion, such 
as sordes in the mouth, membrane on the fauces, severe 
sweating, etc. 

Treatment. — Uncomplicated and mild scarlatina requires 
no treatment during the eruptive stage except to confine- 
ment to bed, the substitution of fluid diet for that of ordinary 
health, and a mild aperient every other day or so. The 
room is to be well ventilated, kept at a uniform temperature 
of 65 °, and the bed and body-linen changed frequently. 
Nevertheless, it is with mild cases that there is so much 
trouble. Perhaps, a child is hardly ill, and the parents do 
not see the necessity of, and the doctor does not insist upon, 
three weeks in bed. It is allowed to get up, perhaps to go 
out of its room, and then dropsy supervenes. Dropsy, no 
doubt, varies in its frequency in different epidemics, but this 
does not alter the fact that it may be averted in many a case 
by timely care. Three weeks, at least, in bed and a further 



I96 THE DISEASES OF CHILDREN. 

fortnight or three weeks in one room make the proper pre- 
ventive treatment for this complication. 

If the eruption is full out and the fever high, a warm bath 
night and morning will give much relief. When the fever 
is excessive, tepid sponging, the cool bath as described un- 
der the head of measles, or the wet pack, must be resorted 
to. For the soreness of throat, an electuary of equal parts 
of the glycerinum boracis and honey may be given in small 
quantities at frequent intervals. 

Inunction is advisable in most cases as soon as the erup- 
tion appears. It relieves the stiffness and itching of the 
skin, it stimulates the circulation, is agreeable to the patient) 
and promotes sleep, and thus indirectly tends to better the 
disease. Carbolic oil 1 X 40 is a very good preparation, 
possessing as it does disinfecting properties. Meigs and 
Pepper recommend cold cream, to which a drachm of 
glycerine per ounce has been added — a very nice prepara- 
tion, which may easily be made disinfectant by substituting 
the glycerinum boracis for the pure glycerine. The inunc- 
tion may be applied as often as necessary — two, or three, or 
more times a day. 

If not resorted to before, a daily warm bath should be 
commenced as soon as desquamation begins. Plenty of soap 
and water and friction hasten the completion of this stage. 
Care must, of course, be exercised to avoid any chill, but 
this can readily be done by having a bath at ioo°, and a 
large, warm towel or sheet to envelop the body during the 
process of drying, and in which the child may be carried 
back to bed. In the more severe cases the temperature will 
probably be higher, and the cooling processes a more im- 
portant element in the treatment. Cold sponging, the tepid 
bath, or the ice-pack must be resorted to more freely ; and, 
in cases where there is much delirium, an ice-cap may be 
applied to the head with advantage. These are cases where 



SCARLATINA. 1 97 

much depends on feeding. The throat is sore, and the child 
refuses food in any shape. It must be coaxed with all the 
variety the nurse or physician can suggest. Barley-water, 
with uncooked white of egg added to it; simple water and 
albumen ; nutrient jellies, blanc-manges, chicken-broth, 
veal-broth, Brand's essence, milk, whey, all readily suggest 
themselves as valuable in turn. To these must be added 
stimulants, either brandy, champagne, or port wine. When 
food by the mouth fails, nutrient enemata must be tried ; 
but, as I have already said, they are not well borne by chil- 
dren. I am disposed to think more highly of the catheter 
passed through the nose into the stomach, and of regular 
feeding conducted through it. As regards local treatment, 
when the faucial inflammation is severe, there is much dif- 
ference of opinion. Meigs and Pepper think that the good 
that might accrue is often nullified by the exhaustion pro- 
duced in the struggles of resistance. I am, however, of 
opinion that, when it can be applied, some glycerine prepa- 
ration gives such relief that children will often submit readily 
to the re-application. I am not prepared to say dogmati- 
cally that one preparation is better than another. Per- 
sonally, I am in favor of boracic acid and glycerine, or that 
in combination with bicarbonate of sodium — at any rate 
whenever there is any tendency to the closing of the fauces 
by viscid mucus or the formation of membrane ; but 
others are equally fond of perchloride of iron and glycerine, 
or chlorate of potassium, etc. The inhalation of steam, im- 
pregnated with carbolic acid or eucalyptol, is always ad- 
visable. And a spray of liquor calcis and the sucking of 
ice are both well worth a trial in suitable cases. 

Internally perchloride of iron, chlorate of potassium, 
carbonate of ammonium, and quinine are the most serviceable 
drugs when drugs are needed. The chlorate of potassium 
may be given in three- or four-grain doses with five or six 

17 



I98 THE DISEASES OF CHILDREN. 

drops of hydrochloric acid and a little syrup of Tolu, etc. 
This is useful in adynamic cases, or when the throat is much 
affected. Carbonate of ammonium is also a valuable stimu- 
lant in severe cases, two or three grains being given in milk 
every three or four hours. Quinine should be given if the 
temperature keep up beyond four or five days. 

Of drugs for cutting short the exanthem, none have as 
yet any claim to trust. Belladonna has been tried and 
abandoned. Hyposulphite of sodium in five-grain doses, 
and sulpho-carbolate of sodium are thought well of by 
some, and salicin is a good remedy when there is much 
fever. 

The complications and sequelae of scarlatina, excepting 
the nephritis, must be treated each of them on its own 
merits ; but this general rule will apply, that, resulting from 
fever, they are generally an indication of the need for stim- 
ulants an.d tonics. 

In scarlatinal dropsy, the child — if not already in bed — 
must be at once sent there. The diet is to be fluid, the 
bowels are to be regularly opened by jalapin (gr. j) or scam- 
mony (grs. v to vij) or seidlitz powder once a day, and the 
skin is to be acted upon by a warm bath night and morning. 
The bath should be 98 to ioo°. The child should be im- 
mersed up to its chin and allowed to remain in it for fifteen 
or twenty minutes, care being taken to keep up the tem- 
perature of the water the while. It is then to be wrapped 
in a dry warm sheet and put to bed again. Should these 
measures not be successful, dry cupping to the lumbar 
region may be added, and frequent hot applications by 
means of spongio-piline. Digitalis should be given inter- 
nally for two purposes — first, to keep up the flow of urine, 
and secondly to guard against the occurrence of dilatation 
of the heart. The tincture may be given with the liq. 
ammonii acetatis and spt. setheris nit. (F. 37) or by itself, in 



SCARLATINA. 1 99 

two, four or five minim doses every two or three hours. 
Ten or fifteen minims of the infusion every three hours is 
sometimes more successful than the tincture. 

Should there be any tendency to suppression of urine and 
should convulsions threaten, immediate and repeated resort 
must be had to all these means. Purgation must be free, 
and bromide and iodide of potassium should be given 
internally. Diuretics are recommended by many, but I 
prefer to trust to the action of bowels and skin rather than 
run the risk of further blocking an organ already at a 
standstill from hypersemic conditions. In this condition a 
warm wet pack — by means of a blanket wrung out of hot 
water — for two or three hours at a time, is very useful, and 
in bad cases I have used subcutaneous injections of pilocar- 
pi, though not with any striking success. 

[Infusion or fluid extract of jaborandi administered by 
the mouth acts very efficiently, especially if combined with 
hot packs. For the latter purpose the child, stripped of its 
clothing, is placed between blankets and surrounded by 
bottles containing hot water and covered with flannel cloths 
wrung out of hot water. The pack should last from ten 
minutes to half an hour, according to the amount of sweat- 
ing and feebleness induced. It may be repeated when there 
is little prostration twice daily, and should the child com- 
plain of faintness whilst undergoing this treatment the 
bottles must be removed at once and a dose of whiskey 
given. 

Hot-air baths are useful in producing diaphoresis, but are 
more apt than the packs to produce faintness and a sensa- 
tion of difficulty in breathing. Heated air may be intro- 
duced, the child being blanketed as before, by a tube 
leading from an inverted funnel held over a gas jet or spirit 
lamp.] 

When the acute symptoms subside — the dropsy diminish- 



200 THE DISEASES OF CHILDREN. 

ing and diuresis becoming established — then is the time for 
iron. Tincture of the perchloride is useful ; under its use 
the albumen will decrease, the blood disappear, and the 
anaemia become much less manifest. Sometimes milder 
preparations are required. If so then reduced iron, or car- 
bonate of iron, or Parrish's food may be resorted to. 

[The following formula, which differs somewhat from 
" Basham's Mixture," is perhaps the best way of adminis- 
tering iron in these cases. 



R. Tr. Ferri Chloridi, 



Addi Acetici DiL, 
Liq. Arnrnonii Acetat., 
Elix. Aurantii, . 
Syrupi, 



f3J 

* .~J iS - 
f 3 x. 



Aquse, . . . . . . . q. s. ad 15 vi. M. 

S. — One tablespoonful three or four times a day, for a child of four 
years.] 

The kidney is not an organ that repairs quickly. Con- 
sequently if the albuminuria is of any duration the child 
must be kept in bed for some weeks. When the albumen 
has disappeared there is still need for much caution. The 
clothing must be very warm — flannel next to the skin — and 
the diet must be of the most assimilable possible. It should 
consist largely of milk for a long time. Open-air exercise 
is to be resorted to gradually, and only at first on the 
warmest days. And if the parents are in a position to allow 
of it, a temporary sojourn at some mild watering-place, such 
as Torquay or Penzance, is very desirable. 

Scarlatinal rheumatism is to be treated by salicin or 
salicylate of sodium in the same way that acute rheumatism 
is treated ; eight or ten grains of the salicylate, or more 
according to age, ma}- be given even' three or four hours 
in acetate of ammonium and syrup till the pain is relieved; 



SCARLATINA. 201 

then it may be continued at less frequent intervals, and sub- 
sequently combined with quinine. 

For the otorrhoea a Gilbertson's syringe should be pro- 
cured and the ear gently syringed with warm spirit lotion 
(5j to ox) three or four times a day. After syringing, a 
little oil (F. 38) should be dropped into the ear, and some 
salicylic wool kept in the meatus. 

When there is a discharge from the nose it is advisable 
to pass up the affected nostril a brush which has been 
immersed in glycerinum boracis, or in an ointment com- 
posed of fifteen grains of iodoform, half an ounce of the oil 
of eucalyptus and vaseline to an ounce and a half. 

Preventive Treatment. — No doubt in the future we shall 
have adequate hospital accommodation for fever patients, 
and homes for those who are convalescent; at present, 
when out of reach of these means, we must come as near 
as may be to the sanitary requirements of the day. The 
child must be kept in the one room, its nurse or nurses 
occupying another on the same floor. All unnecessary 
stuffs and linen, carpets, etc., are to be removed from that 
floor. Sheets steeped in carbolic acid are to be hung from 
the doors of the rooms, and a similar material is to be 
sprinkled freely oyer the floor. No actual contact is to be 
allowed with the rest of the household, and all linen from 
the sick-room is to be steeped in some disinfectant before 
removal. This quarantine must be rigidly enforced and 
maintained throughout the illness — that is to say, until des- 
quamation is completed — an irksome and difficult task 
enough. When the term of quarantine has expired, the 
child should have a final bath, leave all his cloths behind 
him and don a clean outfit outside his room ; after this he 
may be considered to be clean. 

When a case of scarlatina breaks out in a school it is a 
good plan when possible to have the temperature of all the 






202 THE DISEASES OF CHILDREN. 

children taken night and morning. By this means very 
early isolation can be effected, and there is every chance in 
this way of arresting the spread of the disease. 

After the exit of the patient and his nurses, the rooms 
occupied by them must undergo a thorough disinfection. 
Sulphur should be burned in them for some hours. The 
papers stripped, the ceiling rewhitened, the floors scrubbed 
with carbolic soap and all bedding and linen which cannot 
be subjected to prolonged boiling must be sent to some 
disinfecting oven and subjected to prolonged heating over 
212°. Clothing in like manner and, where expense is no 
object, everything in the way of cloth or wool that has been 
contaminated, should be burnt. 



ROTHELN — ROSEOLA. 203 



CHAPTER XII. 

ROTHELN— ROSEOLA. 

Rotheln (Epidemic Roseola ; Bastard Measles ; German 
Measles ; Rubella) — is an affection which appears to have 
been noticed at various times in the last hundred years ; but 
many, even yet, have seen little or nothing of it, and doubt 
its existence. There is not, however, any longer room for 
doubt that an exanthem is occasionally present with us which 
in some things resembles scarlatina, but, in more, measles. 
Originally it was thought by many to be a hybrid between 
scarlatina and measles, now it is commonly supposed to be 
a distinct species. But the one opinion does not exclude 
the other ; there are, e.g., some who think that diphtheria — 
from certain peculiarities in its history and associations — is 
a disease in which the germ of what will be, but is not yet, 
a distinct species is in process of evolving ; that it is in fact 
an illustration of the tendency which plants exhibit of vary- 
ing under domestication — and, indeed, what can be more 
likely ? We know that in the cultivation of plants variations 
occur, and that hybrids are grown which can occasionally 
be propagated so as to constitute them distinct species. 
Why should exanthem germs be — is it probable that they 
are — altogether exempt from such tendencies to variation ? 
Thus, when we have to do with a disease which is at one 
time more like scarlatina, at another like measles, but always 
to some extent like both, and always wanting some of the 
features of both, I see not only no difficulty in considering 
the disease a hybrid, or a derivative of one disease or the 
other, but also none in regarding it as a distinct, though 



204 THE DISEASES OF CHILDREN. 

perhaps as yet but an imperfectly stable, species, and one 
which, regarding its probable source, is of the greatest pos- 
sible etiological value. Naturally we must be very cautious 
in accepting any conclusions upon such a point. Eruptions 
very like scarlatina, very like measles, are undoubtedly pro- 
duced by various articles of food, drugs, and so on. It will 
not do, therefore, to conclude, because of the existence of a 
nondescript rash, that some new exanthem has started into 
existence. I only wish to maintain that there is no inherent 
objection to this derivative view, and that until we know 
more of the nature of the " germ/' it will be as well to keep 
our minds open. But in thus stating dogmatically that the 
existence of a distinct exanthem which resembles two others, 
but is neither, is proved to demonstration ; let me say, as I 
shall again do with regard to Roseola, that the affection is 
an uncommon one, and that the diagnosis is to be arrived 
at with the greatest possible circumspection. " German 
measles " is a term which is terribly abused. A doubtful 
rash makes its appearance, and the medical man, instead of 
saying he is not certain of its nature, calls it German measles. 
" Then it is not scarlatina ?" ask the parents. " No," says 
the doctor ; and the parents, thinking nothing of measles, 
take no precautions. Any hospital physician sees many such 
cases, and knows also very well — considering the rarity of 
the actual disease — that when he has to do with what is 
called German measles, it is more probable than not that the 
nature of the malady is scarlatinal, and that in this direction 
he must look for the explanation of whatever sequelae he 
may meet with. 

As regards its specific entity it may be pointed out, that 
it occurs in epidemics ; that one attack appears to be pro- 
tective against a recurrence ; and that it is no protection 
to have suffered previously from scarlatina and measles. 
Of sixty-three cases seen by Dr. Dukes, thirty-nine had 



ROTHELN ROSEOLA. 205 

had measles, twenty-three had not. If anything, it appears 
to be more common in adults, at any rate in young adults 
or adolescents — a class of whom a larger number are pro- 
tected by previous attacks of scarlatina and measles than 
in younger children. Conversely, those who have suffered 
from rotheln procure no immunity from scarlatina or 
measles. I should add to this that Thomas states that it is 
especially a disease of childhood, attacking indiscriminately 
older and younger children down to sucklings, suscepti- 
bility being essentially weakened at puberty, and nearly 
lost after forty. 

It is very contagious, though less so than measles. The 
infective power is said to exist for a month, so that strictly a 
child should be isolated for that time. But the disease is 
one of so little severity, that, except in the case of weakly 
children, it can hardly be necessary to keep up any strict 
quarantine after ten or fourteen days. As a matter of prac- 
tice, provided one is sure of the nature of the disease, there 
can be but little objection to allowing a child to return to 
school at the end of a fortnight, if thorough disinfection has 
been carried out. 

Definition. — Dr. Squire thus writes of it: "A specific 
eruptive fever, the rash appearing during the first day of the 
illness, beginning on the face in rose-red spots, extending 
next day to the body and limbs, subsiding with the fever on 
the third day, and not preceded by catarrh, nor followed by 
desquamation." 

Incubation. — A fortnight or more during which the child 
is quite free from symptoms. Dr. Dukes records thirty-six 
cases, in twenty-five of which the incubation is given; in 
one or two only was it twelve days, in the remainder four- 
teen up to twenty-two days. 

The Eruptive Stage may be well illustrated by a case : 
a lady who always enjoyed good health, was quite well till 

18 



206 THE DISEASES OF CHILDREN. 

May 20th ; she felt out of sorts and depressed all day, with 
lumps in her neck, and on May 21th, in the early morning-, 
an eruption appeared and I saw her immediately. The tem- 
perature was then 98. 6°, the pulse 80. The face and neck 
were covered with a red raised eruption, consisting of clus- 
tered papules rather thickly set, but the intervening skin 
being white and healthy-looking. There was no soreness 
of throat, but well-marked, rather hard, and not tender, en- 
largement of glands on both sides of the neck. She felt 
perfectly well. The next day the rash had become much 
more diffused ; the face now presenting a livid appearance, 
with a general red ground and lumpy raised elevations 
upon it. Over the chest there was a roseola not unlike 
scarlatina, but less punctate. The temperature still remained 
normal. The next day she was well, and no desquamation 
followed. 

Here we have all the characteristics well marked : twenty- 
four hours of the most moderate indisposition ; the outbreak 
of an eruption like measles, though attended by a roseola 
not unlike scarlatina; the absence of catarrh, such as is 
characteristic of measles ; the absence of desquamation, 
characteristic of scarlatina ; considerable temporary swelling 
of the glands of the neck, but no sore throat, no fever at any 
time; and the affection running its entire course in four 
days. 

Some latitude must be allowed both to the definition here 
given and to the type which is illustrated by the case. For 
instance, the eruption, though usually raised in coalescing 
points like measles, is occasionally diffused, and unquestion- 
ably more like scarlatina ; pyrexia may, or may not, be 
present : it is always moderate when present ; there may 
also be some slight catarrh, and occasionally there is some 
slight branny desquamation. But these features are present 
in only the minority of cases, and will then necessarily tend 



ROTH ELN ROSEOLA. 



207 



to obscure the diagnosis. Dr. Dukes describes a mild and 
a severe form. In the latter the eruption is profuse and the 
temperature up to 103 . Complications and sequelae there 
are none, so that if after an attack of German measles a child 
remains thin and feeble or has any discharge from its ears, 
these things indicate, to my mind, that some error in diag- 
nosis has been made, and the disease was either scarlatina 
or measles. 

Diagnosis. — I have already alluded to the liability that 
there appears to be to mistake rotheln for scarlatina and 
measles. I have only to add that the possibility of eruptions 
produced by drugs and food must be borne in mind when 
forming an opinion, and Dr. Dukes mentions also the fre- 
quent occurrence of a measly rash which is caused by hand- 
ling some species of caterpillar — a very common hobby with 
boys at school. 

Treatment. — The child must be kept warm in one room, 
and in bed, if possible, for a day or two, but this is not ab- 
solutely necessary ; some saline diaphoretic may be given, 
and any mild aperient that may be necessary. Here, as in 
any other exanthem, the clothing must be attended to after 
the attack, the child being kept warm and guarded from 
chills, and, should any debility show itself, an iron tonic 
should be given. 

The room inhabited by the child during the attack must 
be fumigated as for other exanthems. 

Roseola, or rose rash, has no strict right to be considered 
in association with the specific exanthemata ; but the chief 
point of the affection is the difficulty of the diagnosis — a 
question of such moment as quite to justify the departure 
from any mere scientific arrangement. Rose rash is an 
irregular mottling or blush upon the skin, dependent appa- 
rently upon gastric disturbances. It wants the minute 
bright red punctiform appearence of scarlatina, and is 



_ ; 8 THE DISEASES OF CHILDREN. 

sometimes more like measles in mottling the skin. It is 
dally diagnosed by the absence of any definite symp- 
toms of scarlatina, and, experimentally, by the fact that it 
has not in any given case spread by contagion. 

But let it be indelibly impressed upon the student that it 
is often very difficult to distinguish this complaint from 
scarlatina, and that a mistake may be followed by the 
gravest consequences. Many a case :: rose rash has 
proved itself in the result to have been scarlatina. There- 
fore, unless there is no doubt, it is safer to take precautions 
as if the more serious disease were present. Rose rash 
stands in this respect with surgical scarlatina or membra- 
nous croup. It is probable that there are scarlatina-like 
eruptions which are not scarlatina, and membranous inflam- 
mations of the larynx which are not diphtheritic, but they 
can seldom be distinguished. Many such cases prove 
indisputably to be of the graver sort, and for the safety of 
others, in default of conclusive evidence to the ; ntr :.:y, all 
should be so regarded. So too should it be with roseola, 
for scarlatina now stalks about as often as not in the garb 
of innocence, and does incalculable harm both to the pa'tient 
and to those with whom he comes in contact. For instance, 
two children suffer from a red rash, called rose rash by the 
doctor, who commits himself positively to the non-scarla- 
tinal nature of the affection. But subsequent observation 
shows that they have sore throat int in the house 

has a bad throat ; and the aunt also has a bad throat, and is 
unwell for some weeks. Of the patients the: 30th 

subsequently have enlarged cervical glands and desquama- 
tion, and one has discharge from the ears and albuminuria. 
Another child has what is called rose rash ; but it remains 
and has discharge from its ears, and 
does not regain strength foi >3me weeks. Now, inasmuch 
as roseola is a ent and trifling matter, and is fol- 



ROTHELN ROSEOLA. 



209 



lowed by no sequelae, when a child remains weak and thin, 
with a red raw tongue, dry skin, and has discharge from the 
ears after such an attack, it is probable that a mistake has 
been made in the diagnosis, and that scarlatina has been 
the disease. The above are both cases that actually oc- 
curred, and every one of us must know of many more of a 
similar kind. A more careful examination of such cases, 
with this in mind, will often lead to the detection of a gen- 
eral fine branny desquamation, or some flakiness of the 
cuticle on the hands and feet. Such children, I say, are 
abroad in numbers, wholesale purveyors of scarlatina; and 
they will continue to be so, so long as roseola or rose rash 
is of common occurrence. Our attitude is not to ignore its 
possible existence, but to accept it only upon the strongest 
evidence ; and the usually accepted evidence — viz., absence 
of pronounced symptoms of scarlatina — is not strong enough, 
for there is no disease which is more variable both in the 
intensity of single symptoms, and in the grouping of those 
which may be considered typical. 

Treatment, — When we are sure that we are dealing with 
roseola, very little treatment will be required. Some simple 
saline, such as citrate of potassium with acetate of ammo- 
nium, and warmth in bed for twenty-four hours, with lighter 
diet for a day or two, will probably be all that is necessary. 



2 I : THE DISEASES OF CHILDREN. 



CHAPTER XIII. 

DIFHTHEBI*. 

Diphtheria is a disease very frequent amongst children; 
it is most common between the ages of two and ten. It is 
usually considered to be due to a specific poison, because it 
is often epidemic and it is certainly contagious. But there 
are points in its natural history which differ much from 
many other specific fevers, and of these it may be mentioned 
that its contagious power is not a very high one. It is com- 
municated by one patient to others hy means of inoculation 
from a materies derived from the diseased parts, and thus 
doctors and nurses are chief sufferers ; an imperfectly disin- 
fected tracheotomy tube may impart it ; and a healthy child 
put into a bed or a particular corner of a room recently 
occupied by a diphtheritic child may thus u catch " the 
disease; but it is not communicated to other children or 
patients in a building, or carried about in clothing like 
measles or scarlatina.* It has also a curious tendency 
much more frequent with it than with other specific fevers, 
though not unknown in them, of tacking itself on to some 
other fever. Thus measles followed by diphtheria, scarla- 
tina followed by diphtheria, typhoid fever followed by or 
going with diphtheria, are all well known and not uncom- 
mon. Epidemics of all these three — measles, scarlatina, 
and typhoid — occur in which diphtheria attacks man}-, so 
that some have thought it wanting in specificity and capable 
of being bred out of these diseases. Irs relationship to 

* Many authorities hold that diphtheria is contagious in the ordinal} 

::" :r.i :-:... — E~ . 



DIPHTHERIA. 



21 I 



scarlatina appears to be unusually close. Again, if mem- 
branous croup and diphtheria are one disease, as very many 
now hold, diphtheria is endemic, for sporadic cases are 
common and appear to keep company in a large number of 
- with no other known source of contagion than bad- 
smelling drains. There is indeed much to be said in favor 
of a pythogenic origin denoi'c cases. It From 

other n having no proper eruptions attaching 

to it, being often without any at all ; it 

one of scarlatinal character, sometimes one like that of 
measles, more often perhaps an anomalous patchy roseola 
— in virulent cases the rash may be petechial. Las 

specific affections, diphtheria has no powerful 
protective infi ust anrther attack at some fut 

time. 

Incubation. — This stage appears to be somewhat uncer- 
tain. It ranges from two tc tight cays — three days being 
a usual time :: elapse between the reception of the germ 
and the first symptom. 

The Eruptive Stage is characterized by the formation of 
tough yellowish or grayish membrane upon a mucous sur- 
face, generally of pharynx or larynx, combined with hocal 
inflammation. The local symptoms are associated with 
certain so-called constitutional symptoms — viz., fever and 

uminous urine. Different cases vary in many respe 
The type is pharyngeal diphth- sometimes the mem- 

brane forms not up : n the fauces, but on the cc va or 

the labia pudendi, oftentimes in the larynx. Sometimes it 
in great measi ir :- confines itself to the nasal mucous mem- 
brane; sometiir.es it may be found upon the lips, sometimes 
on some sore up?:: the skin; sometimes e nbrane is 

present, yet the remainder oi the symptoms make the c 
indistinguishable from one of diphtheritic nature. Sc 
the albuminuria. In some cases it is much and persistent; 






212 THE DISEASES OF CHILDREN. 

in others it is moderate in quantity throughout ; in others 
the albumen quickly disappears. The pyrexia too may be 
of all grades of intensity : sometimes so little that the child 
is able to sit up in its bed and play with its toys ; sometimes 
the constitutional disturbance is so severe that the condition 
is desperate even from the commencement. 

Pharyngeal Diphtheria. — The onset is usually some- 
what leisurely, the child is out of sorts, heavy-eyed, languid 
and pale, for four or five days, by which time the tempera- 
ture reaches perhaps ioi°. The throat is now seen to be 
red and swollen, and predominance of redness or lividity 
over swelling is of evil omen. The appearance of the 
throat in a simple tonsillitis is, usually speaking, a more 
juicy or cedematous one than the perhaps less swollen, but 
firmer-looking, thickening of the parts in diphtheria, and the 
swelling is more often unilateral. The membrane begins as 
small patches of yellowish material, not in themselves dis- 
tinguishable, or at any rate certainly so, unless perhaps 
occasionally by their dirty color, from the plugs of welded 
epithelium and secretion which issue from the mouths of 
the follicles of the tonsils in the course of tonsillitis, both 
acute and chronic. Their nature has to be decided by their 
position — if they are on the soft palate, provided of course 
that we are not dealing with thrush, they are of membra- 
nous nature — by their roughness, by the general appearance 
of the throat, by the constitutional symptoms, pain in swal- 
lowing, fever, and glandular swelling. At this time the 
glands beneath the angle of the lower jaw on one or both 
sides should be hard, tender and slightly enlarged, but the 
swelling need not be much. In cases of severity it is often 
considerable. The diphtheritic plaques tend to increase in 
area, and to coalesce ; they adhere rather stoutly to the 
surface of the palate or tonsil, and when removed a shallow 
ulcer is seen, with numerous bleeding points upon it. The 



DIPHTHERIA. 



213 



urine is usually of good color, good specific gravity, and a 
moderate cloud of albumen is precipitated if cold nitric acid 
be added. It but seldom contains blood. Hyaline and 
occasionally epithelial casts may be found by examination 
of the urinary sediment microscopically. 

[In addition to the symptoms above mentioned there are 
early in the attack : chilliness, pain in the back and limbs, 
headache, thirst and fever. Prostration, in proportion to the 
length of time the patient has been ill, is very marked. The 
pulse is frequent, weak and easily compressed. Opening 
the jaws produces considerable pain, and the neck is fre- 
quently much swollen. The breath is very fetid, and at 
times membrane tinged with blood is coughed up. The 
voice is altered, and the cough, should the larynx be in- 
volved, is croupy.] 

In a case of this kind terminating favorably, the mem- 
brane perhaps remains in situ for some three or four days, 
and then slowly disintegrates, disappearing in perhaps ten 
days from its first appearance, and the child slowly regains 
its former state of health. When the membrane clears 
away, a somewhat indolent, though shallow, ulcer is usually 
left behind, which is often slow in healing up, and is fol- 
lowed, or not, as the case may be, by paralysis of the soft 
palate. And this may be so even when the evidence of real 
illness has been but slight. In favorable cases the albu- 
minuria disappears, sometimes with peculiar suddenness, in 
a few days, but it may last even in considerable quan- 
tity for some time after the subsidence of the throat symp- 
toms. 

Modifications. — (1) There may be much membrane about 
the soft palate and fauces, and very little constitutional dis- 
turbance, and no albuminuria — e.g., a girl, aged ten years, 
had been ill for twelve days with sore throat. . The urine 
contained no albumen at any time, the temperature only 



2T4 THE DISEASES OF CHILDREN. 

reached 99 , and she hardly seemed ill, yet the sides of the 
fauces were covered with membrane, her cough was croupy, 
and there was decided dyspnoea. She was treated with chlo- 
rate of potassium, perchloride of iron internally, and a local 
application of bicarbonate of sodium, and recovered. (2) 
The membrane may be considerable, the constitutional symp- 
toms slight, but albuminuria considerable, and after a few 
days the child may die almost suddenly, either from collapse 
or sudden syncope. (3) The throat affection maybe severe, 
the fauces, soft palate, and uvula being covered by thick 
leathery lymph, and some parts perhaps sloughing, in which 
case the constitutional symptoms will almost certainly cor- 
respond in severity. In such cases the nasal mucous mem- 
brane is liable to suffer, and a thick offensive discharge issues 
from the nostrils and crusts and about the anterior nares. 
In these cases the fever is high, the pulse rapid, the albu- 
minuria copious, and the prostration and somnolence pro- 
found. [These cases if seen early usually present the livid 
appearance about the mouth and the anxious facial expression 
so indicative of obstructed respiration. At the same time 
there is a foul, acrid, serous and sometimes bloody discharge 
from the nostrils which produces excoriation and swelling 
of the upper lip.] (4) The throat symptoms may be slight, 
the fever severe, and the general symptoms those of bad 
blood-poisoning, death occurring within a day or two, or 
even less. (5) The fauces may show no membrane, but the 
tonsils and parts around are in a condition of acute phleg- 
monous inflammation. I have seen cases of this kind where 
the tonsils have been sloughing out en masse, and in which 
death has occurred by sudden failure of the heart. (6) The 
laryngeal symptoms may be paramount, or the disease may 
be entirely confined to the larynx, but there can be no 
doubt that in many of these cases (called " croup") the 



DIPHTHERIA. 



215 



early faucial inflammation has been overlooked from the 
insidious manner of onset peculiar to the disease. 

Causes of Death. — No case of diphtheria, however mild, 
is free from danger. The risks are chiefly four : 

1. Of blood-poisoning. 

2. Of some inhibitory action upon the heart, causing slow 
pulse and syncope. 

3. Of asthenia. 

4. Of extension of the membranous inflammation to the 
larynx, with all the consequences which this involves. 

The last mentioned is, in hospital experience, much the 
more frequent, but perhaps this is only due to the fact that 
as such cases require operative treatment and very special 
nursing, they are therefore more likely to be sent into a 
hospital. 

But to take the various risks in order. 

I. Blood-poisoning carries off some. Cases of this kind 
are usually severe from the commencement — probably the 
throat symptoms are excessive; the nostrils involved; the 
membrane is plentiful, tough, and dark-colored ; the breath 
fetid ; the albumen copious ; the temperature high ; and the 
pulse rapid and feeble. Four or five days sees the termina- 
tion of such a case as this, and death comes either by som- 
nolence, gradually deepening into coma ; or more suddenly 
by a rapidly falling temperature, coldness of the extremi- 
ties — perhaps profuse sweating — and a general lividity of 
the surface ; a condition, in short, of septic collapse. 

2 and 3. All acute inflammation about the fauces show a 
tendency to cause slowing and irregularity of the pulse ; this 
is specially the case with diphtheria and constitutes one of 
the great dangers of the disease. Moreover, the symptom 
is by no means confined to cases of severity, and the risk 
appears to attach not only to the acme of the disease, but to 
the period of convalescence afterwards. Cases are on record 



2VZ THE DISEASES 17 IHILZZZN. 

in which sudden syncope has ensued after all membrane had 
disappeared from the fauces, and the ulcers, remaining were 
healing satisfactorily. The pulse will sink to 50, 40 or even 
.ess — Hillier says even so low as 20 — per minute, and be- 
: : . e : r e g a r ; this condition being associated perhaps with 
vomiting, and the child is said to die quite suddenly. I 
have lately made an inspection of the body of a boy of four, 
under the care of my colleague, Dr.-Wilks, who had been 
ill six weeks, and had had paralytic symptoms for a fortnight. 
He was a thin s.~?z~ : .c b : y. and appeared to die from exhaus- 
tion. The left ventricle of the heart was widely dilated, 
although the muscular tissue looked healthy. It may also 
be added that, in addition to this disordered innervation, 
the action of the heart may be exceedingly feeble from fatty 
degeneration of the muscular fibres of its wall. 

4. The greater proportion of deaths are due to suffocation 
caused by the extension of the membrane from the fauces 
into the larynx and trachea, or by a more or less general 
broncho-pneumonia due to this, or to this and the operation 
of tracheotomy resorted to for the relief of the asphyxia. 
This also is a complication which is more likely to ensue in 
the cases of moderate severity than in those which run a 
more rapid course, and, as I have already said, it appears 
ofttimes to be the primary affection. But careful inquiry 
generally serves to show a period of four or five days' ma- 
laise, and I have known laryngitis to foHow pharyngeal 
diphtheria so late as the twelfth day. Some still doubt 
whether there is such a thing as an uncomplicated laryngeal 
diphtheria — that is to say, whether there is not in all cases 
some, even if it be but slight, faucial disease as well. Others, 
on the contrary, go so far as to say that whenever a mem- 
branous laryngitis is met with it is due to diphtheria ; in 
other words, that membranous croup is always diphtheritic. 
If this be correct, the other opinion cannot be ; as it is quite 



DIPHTHERIA. 



217 



certain that a membranous laryngitis is met with in which 
the fauces are free. In these cases there is slight malaise 
for three or four days ; then a noisy reedy cough is noticed, 
and slight inspiratory stridor. The temperature of the body 
is as yet hardly in excess, although even already the urine 
may be albuminous. The noisy hissing respiration increases, 
the temperature rises, the child becomes more and more 
restless, the features become livid and then leaden, and un- 
less the windpipe be opened, death ensues shortly from suf- 
focation. The best guage of laryngeal obstruction is the 
recession of the weaker parts of the chest walls during in- 
spiration ; that of a pressing deficiency of aeration is rest- 
lessness. A diminution of restlessness accompanied by the 
onset of a leaden pallor of the features, betokens impending 
dissolution and the immediate necessity of tracheotomy. 

Complications and Sequelae. — These are not numerous, 
albuminuria and paralysis are the chief of them. Moreover, 
it may perhaps be mentioned that at times a somewhat deep 
ulceration may be met with about the tonsils, which is slow 
in healing ; and at times though far less commonly than in 
scarlatina, a diffused brawny swelling of the connective tis- 
sue of the neck, such as has of late years received the name 
of Angina Ludovici. 

The albuminuria of diphtheria requires mention for many 
reasons. It is remarkably constant, though the quantity of 
albumen passed varies much ; should it be persistent, and 
the quantity of albumen be large, although in other respects 
the child may seem to be doing well, the prognosis is of 
considerable gravity. One may notice further that it is a 
symptom of the disease — being present at an early period of 
the attack, generally by the third or fourth day ; that the 
urine is not as a rule characterized by scantiness, or the 
presence of blood, and that casts, if present, are hyaline and 
not epithelial ; that it leads to no after-symptoms, such as 



2l8 THE DISEASES OF CHILDREN. 

dropsy ; and that the kidney does not usually show any defi- 
nitely marked change. Thus essential differences are estab- 
lished between the albuminuria of diphtheria and that of 
scarlatina : in the one it is an early symptom, in the other 
a late one; in the one the urine is not characteristic, in the 
other it contains blood and epithelial casts ; in the one it has 
no after-effects, in the other dropsy is the rule ; in the one 
the kidney shows no definite structural change, in the other 
there is a recognized form of nephritis. Gerhardt has found 
peptones in the urine of diphtheria. 

Diphtheritic Paralysis, unlike the albuminuria, is an 
affection of the convalescent, and declares itself usually 
after two or three weeks by a paralysis of the soft palate. 
This is known by the peculiar alteration of the voice, and 
oftentimes by food coming through the nose in swallowing. 
But the paralysis is often much more extensive than this. 
It may extend to the external ocular muscles and cause 
squint; to the ciliary muscle and cause dimness of vision 
from erratic accommodation; and to the muscles of the 
trunk and extremities producing a general paralysis, in 
which the child is unable to hold anything or to feed 
himself, or he staggers about in a tipsy way, such as is 
very liable to be mistaken for the symptoms of cerebral 
tumor if the practitioner be not on his guard. I have 
seen more than one instance of this in out-patient prac- 
tice, where the history of diphtheria has been, as it may 
be, very unobtrusive. It is further not uninteresting to note 
that in diphtheritic paralysis the patella tendon reflex is 
often absent, and this fact, together with the occurrence of 
disturbances of vision, has in adults led to a mistaken diag- 
nosis of ataxie locomotrice. Deafness, loss of taste, and 
disturbance of common sensation are quite occasional. 
Paralysis is to diphtheria what dropsy is to scarlatina, a 
symptom which often leads to the detection of a hitherto 



DIPHTHERIA. 



219 



unsuspected ailment. But in calling diphtheritic paralysis 
an affection of the convalescent, we must not forget that in 
the active stages of the disease we have also a paralysis 
which constitutes one of the gravest dangers of diphtheria — 
viz., paralysis of the heart ; one can but suppose, indeed, 
that this is only a part of the same tendency to the implica- 
tion of the nervous centres as is seen in the stage of con- 
valescence, and that in those terrible cases of sudden death, 
which are by no means uncommon both during the disease 
and convalescence, we have some sudden disturbance of 
the vagus, brought about by means of its cardiac branches. 
Morbid Anatomy and Pathology. — The fauces are more 
or less swollen, and covered with lymph ; but the extent of 
the swelling and the amount of lymph may alike be small. 
In the most severe cases the uvula and surface of the 
pharynx generally are sloughy-looking, or the tonsils and 
adjacent mucous membrane are boggy or much thickened 
from a diffuse inflammation. In later stages the parts may 
be much defaced by deep ulcers — I have myself seen all 
these conditions. But the majority of cases which prove 
fatal, at all events of those in hospital practice, do so from 
laryngitis and extension of inflammation down the trachea. 
The mucous membrane of the epiglottis is thickened and 
crinkled, and a tough adherent membrane lines the laryngeal 
surface of the epiglottis and the interior of the larynx above 
the true vocal cords ; it often extends from these parts over 
the edge of the epiglottis to the base of the tongue, and 
over the ary-epiglottic folds to the mucous membrane of the 
pharynx; and the reflection of mucous membrane from the 
pharyngeal aspect of the larynx to the pharynx proper is a 
favorite seat for membrane, and one too from which it is not 
easily detached or reached by local applications. As soon 
as the trachea is reached, the character of the membrane 
alters — it loses its toughness, all firm adhesion to the tra- 



220 THE DISEASES OF CHILDREN. 

cheal mucous membrane ceases, and it is only in exceptional 
cases that any tough cast of the respiratory passages is ob- 
tained ; by careful manipulation with water a flimsy cast 
may frequently be separated from the trachea and larger 
bronchial tubes ; but it is more common to find the passages 
full of a thick puriform mucus with shreds or granules of 
membrane, the mucous membrane beneath being mottled 
and thickened from a diffuse inflammation of the submu- 
cous tissue similar to that found in the pharynx. The 
mucous membrane often fails to show any intensity of 
inflammation, as judged by injection. The extent of disease 
is apparent more by superficial ulceration, minute points of 
suppuration or early membranous formation, and a general 
pink and yellow mottling of the whole surface. The smaller 
bronchial tubes are usually full of thick pus, and the lungs 
in a state of more or less diffused broncho-pneumonia com- 
bined with atelectasis. It must be remembered that in 
nearly all these cases tracheotomy has been performed some 
hours, if not days, before death, and therefore that the mor- 
bid appearances below the larynx ought perhaps to be con- 
sidered as a combined result of the disease, and of the 
operation rendered necessary by it to avert impending 
suffocation. 

But little more need be said — membrane is very occa- 
sionally found in other parts of the body, the gastroin- 
testinal tract, the genital passages, and the intestine should 
be examined; and throat affections are sometimes asso- 
ciated with anomalous appearances, such as swelling and 
injection of the glandular patches and solitary glands, or 
perhaps some more diffused enteritis, although no actual 
membrane may be present. But all such things are rare. 
Certain negative facts, however, are probably not unimpor- 
tant — first, that the spleen, which in most conditions of 
blood-poisoning is large, soft, or pulpy, in diphtheria is not 



DIPHTHERIA. 



221 



of abnormal size, and is usually firm ; secondly, the kidneys 
show no change whatever to the naked eye, nor is anything 
very decisive found by microscopical examination. Small 
foci of micrococci with some associated disseminated ne- 
phritis are said to be present. Lastly, I would note, as a 
point which is perhaps not without value in reference to the 
pathology of the neuro-paralytic symptoms of this disease, 
that in some cases, in particular epidemics of diphtheria, 
meningitis has been found. I have myself once seen such 
an association of morbid changes, but it is a very rare con- 
dition in my experience, and apparently in that of other 
English pathologists. The diphtheritic paralysis appears to 
be due to a species of anterior polio-myelitis of somewhat 
irregular distribution. There are now some sixteen cases 
published by Dejerine, Abercrombie, Kidd, and others, and 
in all much the same changes have been found. It is, how- 
ever, worth remark that no after-results, such as infantile 
paralysis, have ever yet been recorded ; it would appear 
that most cases get perfectly well, though some die, but that 
between these two extremes there is no mean of permanent 
paralysis. 

Pathology. — This has been already trenched upon in the 
opening remarks, but repetition will not be out of place in 
a matter of so much importance. Diphtheria is a contagious 
blood disorder — some would say a specific blood disorder, 
meaning thereby a disease due to some definite and constant 
germ ; but I avoid the term specific, because there are pecu- 
liarities about the disease which must to some extent raise 
a doubt whether it may not result from varied causes. For 
instance, it is associated with or comes on after so many 
different specific diseases. It is a frequent accompaniment 
of measles, of typhoid fever, of scarlatina. Exposure to 
the effluvia of bad drainage notoriously often precedes its 
occurrence, and catarrh and chronic inflammation of mucous 

19 



222 THE DISEASES OF CHILDREN. 

surfaces predispose to it. Secondly, it is not protective 
against subsequent attacks. Per contra and in favor of spe- 
cificity, we have the fact that it occurs in epidemics ; that 
the period of incubation is fairly constant ; that the symp- 
toms are also uniform ; and that there is abundant proof, 
both by cases and experiment upon animals, that the disease 
is transmitted by contagion. 

In bygone years, not yet far removed, it has been much 
discussed whether the disease is a local or a general one ; 
but in view of the now prevailing doctrine, that all specific 
fevers are due to the introduction into the blood and tissues 
of germs from without, that question loses much of its point. 
All such affections must now be held to be more or less 
local at first. The difference lies in this — that while some 
germs gain entrance by several doors, or diffuse themselves 
with great rapidity by many means, others proceed by more 
isolated routes, and generate themselves only after some 
process of maturation in the seat of infection. To the latter 
kind belongs diphtheria. This is well shown in the case 
recorded by the late Dr. Hillier, of an eminent surgeon who 
pricked his finger in the operation of tracheotomy upon a 
child for croup. The next day the puncture became painful. 
The following day a pustule formed, and a day or two later 
the cutis sloughed. This was followed in six days by 
diphtheritic deposit on the tonsils ; and, a month later, there 
was paralysis of the soft palate, partial paralysis of the fingers 
and legs, and some impairment of sensibility. To this case 
many others could be added, where medical men have been 
inoculated by ejecta from the throat and fauces, while en- 
gaged in painting the throat, in operating, or in clearing the 
trachea of membrane. Others could be cited where kissing 
has conveyed the contagion. Diphtheria, then, is the result 
of a germ introduced from without by direct contact. It, 
generally speaking, fixes itself upon the fauces or throat, and 



DIPHTHERIA. 



223 



becomes generalized from thence ; but supposing it to gain 
an entrance by some other channel, such as the conjunctiva 
or skin, it still is liable to show a partiality for the fauces, 
and to appear, sooner or later, as a membranous exudation 
on that part. The contagion is not one which readily dif- 
fuses itself, and therefore direct contact is the chief source 
of its propagation ; but in this way it is possessed of consid- 
erable vitality, which evinces itself by the persistent way in 
which it clings to a particular room, a bedstead, or articles 
of furniture once contaminated by the sick child. I have 
more than once seen a patient infected by means of a bed- 
stead which had undergone what was supposed to be thor- 
ough disinfection. 

The infecting germ is supposed to be the micrococcus, or 
the bacterium termo. These bodies, fixing themselves upon 
the bed they choose, be it the catarrhal throat, the hyper- 
trophied tonsils, the cutaneous sore, or otherwise, form a 
membrane by their own growth and the exudation of a 
fibrinous material from the affected tissue. At the same 
time they gradually work themselves into the tissues, into 
lymphatics and the bloodvessels, and thus are carried to all 
parts of the body. Taking the kidney and the brain par- 
ticularly as the parts from which definite symptoms of the 
disease emanate, we -may pursue the life-history of these 
bodies further, and we shall find that in the kidneys they 
grow in foci about the organ, blocking up branches of the 
smaller bloodvessels and branches of the capillary tufts. 
Thus is brought about a cause of thrombosis, of ecchymosis, 
and therefore of albuminuria ; while in the brain the same 
blockage of the small vessels may lead also to capillary 
hemorrhages and softenings, and thus may be explained the 
paralytic conditions which exist so often. 

[In a paper on the Nature of Diphtheria, published in 
1882, Drs. H. C Wood and H. F. Formad arrive at the con- 



224 THE DISEASES OF CHILDREN. 

elusion that diphtheria is " a putrid sore throat with or 
without a secondary constitutional septicaemia, " and assume 
that the cause of diphtheria " is not a specific organism dif- 
ferent from that common to healthy and inflamed throats 
but is an active state of that organism." I prefer, however, 
to look upon diphtheria as a constitutional affection, and 
am supported in this view by many authorities, among 
whom may be mentioned Meigs and Pepper, W. H. Day, 
and J. Lewis Smith. The latter states the following facts 
in this connection : 

1. It is a law in pathology, that those diseases that have 
or may have a long incubative period — say of a week or 
more — are constitutional. 

2. Another fact which indicates primary blood-poisoning 
in diphtheria, is observed in certain cases, namely, the 
occurrence of severe constitutional symptoms for a longer 
or shorter time, perhaps for half a day, before the appear- 
ance of the usual inflammation. 

3. The quick succumbing of the system in certain malig- 
nant cases is evidently due to diphtheritic toxaemia. 

4. Important evidence of the constitutional nature of diph- 
theria is afforded also by the state of the kidneys.] 

Diagnosis — Croup and Diphtheria. — The student must 
be prepared with some ideas on a question of such impor- 
tance as this. I have already mentioned incidentally that 
there are many who think nowadays that all cases of mem- 
branous croup are diphtheritic — that membranous croup is 
that form of diphtheria which attacks the larynx. The points 
of distinction usually drawn are these : Croup is a sthenic 
disease, diphtheria is a disease attended by prostration ; in 
croup the urine is not albuminous, in diphtheria it is ; croup 
is not followed by paralysis, diphtheria is ; croup is not an 
epidemic disease nor is it contagious, diphtheria is both. 
But none of these distinctions suffice for their purpose, be- 



DIPHTHERIA. 225 

cause cases of croup are of frequent occurrence, in which 
holding perhaps at first, they fail afterwards ; perhaps by 
the appearance of albumen in the urine, as is most common; 
perhaps by some evidence of the possession of contagious 
properties, as the attack of two children in one house; or it 
may be by its appearance in an epidemic form. Moreover, 
it cannot now be contended that diphtheria is always at- 
tended by prostration — laryngeal diphtheria need not be at- 
tended by any such evidence of debility from its beginning 
to its end. Such cases frequently terminate purely by 
broncho-pneumonia and asphyxia. The question of conta- 
gion, again, depends much upon the existence of epidemic 
disease — all sporadic disease is less prone to exhibit conta- 
gious properties. Thus, of symptoms, those of disordered 
innervation alone remain as distinguishing between one dis- 
ease and the other, and these are not available for the pur- 
poses of diagnosis at the time when it is all-important to 
form an opinion. 

Some have taken up other ground, and have appealed to 
the local lesion to help them ; and Oertel, admitting the ex- 
istence of two forms of membranous laryngitis, maintains that 
the presence of a profusion of micrococci and of bacterium 
termo in a membranous exudation is sufficient to determine 
against a simple fibrinous inflammation, sufficient to allow 
one to predicate the speedy formation of membrane upon 
a part hitherto free. But I hesitate to indorse such a state- 
ment, although it be backed by such a competent authority. 
I prefer to teach, what I believe, that there are no certain 
histological differences which will allow us to distinguish 
by microscopic aid between a diphtheritic and a non-diph- 
theritic membranous laryngitis. My own opinion is, that 
there are grounds sufficient for a belief in the existence of a 
non-diphtheritic as well as of a diphtheritic membranous 
laryngitis ; but, inasmuch as it is admittedly impossible to dis- 



226 THE DISEASES OF CHILDREN. 

tinguish readily and certainly in doubtful cases between the 
two, and the question of contagion is involved in the decision, 
it is best to consider all cases as diphtheritic, and to take 
precautionary measures in accordance with that assumption. 

[Meigs and Pepper confess that, apart from sporadic cases, 
they are unable to detect any difference between pseudo- 
membranous croup and cases of so-called primary laryngeal 
diphtheria, when the angina is trifling, and is rapidly fol- 
lowed by the formation of pseudo-membrane in the larynx. 

J. Lewis Smith states that the diagnosis of diphtheria from 
membranous croup, though possible in typical cases, in 
localities where diphtheria is not endemic or epidemic, is 
difficult, if not impossible, at the bedside, in localities where 
diphtheria prevails, especially when there is little or no exu- 
dation in the fauces. 

Ellis remarks that, " despite the high authorities who urge 
the identity of these diseases, I confess to remaining uncon- 
vinced."] 

Scarlatina may be mistaken for diphtheria, but the points 
of distinction are numerous, and in well-marked cases should 
be decisive. The attack is sudden in onset, the pyrexia in 
like manner quickly attains a persistent altitude, the fauces 
are more generally reddened, and the strawberry tongue is 
present. There is none of the characteristic membrane. 
Albuminuria is a sequela, not an early symptom, and it is 
associated with dropsy and haematuria. Lastly, endocardi- 
tis and rheumatism may follow up scarlatina. 

[Endocarditis is not an infrequent occurrence in diph- 
theria. Its presence should influence the prognosis or the 
attack, and put us on guard against the development of 
chronic endocardial lesions and their accompaniments. 

Heart-clot also sometimes occurs. It is most often de- 
veloped about the time that the patient enters upon con- 
valescence.] 



DIPHTHERIA. 



227 



In tonsillitis the onset is sudden ; the swelling great and 
oedematous ; often unilateral, without glandular enlarge- 
ment. It is not a very common disease in childhood, except 
in mild form, as part of the history of a chronic condition. 

Treatment. — Our present knowledge, which is derived in 
part from experiment, in part from the experience of the 
records of cases, teaches, as has been already said, that diph- 
theria is due to a germ, which effects a lodgement usually in 
the fauces or respiratory passages, undergoes a process of 
incubation, and subsequently becomes generalized. This 
is the central point from which much of our treatment must 
be directed. Diphtheria is in great part a local disease, and 
is to be treated in great part by local measures. Unfortu- 
nately, the poison in some cases becomes very rapidly gen- 
eralized, and the child then suffers from a bad form of blood- 
poisoning, which deprives the local affection of its primary 
importance ; and it must also be added, that hitherto local 
treatment has not been very successful. Thus, internal 
treatment being by no means unimportant, has, perhaps, in 
its more easy applicability, hindered the thorough persever- 
ance in local measures. But neither is the local treatment of 
ringworm very successful — certain!}' not if anything short of 
the most thorough measures be adopted ; neither is the local 
treatment of cancer very successful. But in neither case are 
local measures discarded ; the whole tendency of modern 
teaching is to make our local treatment of these diseases 
more searching; and so it must be with diphtheria. The 
parallel I would draw between diphtheria and ringworm of 
the scalp is a particularly apt one ; for both, according to 
present knowledge, are parasitic, and ringworm is acknowl- 
edged to be readily curable, so long as it is superficial, and 
does not dip into the hair follicles. I believe a similar inva- 
sion of the follicles, and even deeper structures, is a leading 
feature of the resistance of diphtheria to local measures. 



228 THE DISEASES OF CHILDREN. 

When superficial, it is easily kept at bay; but when the 
whole surface, follicles and all, are stuffed with micrococci, 
the local treatment fails to arrest the growth, and the failure 
of what is — let us acknowledge it at once — a troublesome 
treatment, paralyzes our energies, and the growth of mem- 
brane conquers. I say local treatment is troublesome. It 
is easy enough to order the application of a spray to the 
throat; it is easy enough to order the fauces to be swabbed 
with this or that gargle or lotion ; but orders of this kind 
usually result in some utterly ineffectual application. To 
keep diphtheritic membrane at bay, the application must be 
thorough, and, it may be, frequently repeated. This means 
a frequent disturbance of a child whose only want, perhaps, 
is to be let alone ; and a thorough application of anything 
to the fauces means generally that the strong resistance of 
a struggling child has to be encountered — perhaps taking 
two people to hold it whilst a third attends to the throat — 
perhaps necessitating a gag ; and all this with an amount of 
sputtering, gasping, and choking from the irritation of the 
epiglottis and larynx, such as makes the parents recoil from 
it with dread, so that only the strongest determination and 
belief in the value of the means will enable the physician to 
persevere. No one who accepts the bacterial nature of the 
diphtheritic process, who clearly realizes the nooks and 
crannies of the throat and fauces in which membrane de- 
lights to grow, and the difficulties of management of unrea- 
soning childhood, will have any difficulty in understanding 
why local treatment has often failed — why local treatment 
will often fail again. But this will not deter him from re- 
turning to the attack with all possible additional aids and 
suggestions. And whatever we may think of the nature of 
the disease, that treatment will, I believe, be, in the long 
run, the most successful, which, while doing everything pos- 



DIPHTHERIA. 



239 



siblc to support the child, is ever on the alert to combat the 
formation of membrane. 

For treatment, then, first and foremost, I place local ap- 
plications, undeterred by the fact that they have often proved 
ineffectual. And of local measures, I prefer the applica- 
tion of antiseptics rather than escharotics. They must be re- 
peated as often as membrane begins to form on the surface ; 
and since prevention is more easy than cure, whatever local ap- 
plications be adopted should be applied at regular intervals, 
until the chance of fresh formation of membrane be altogether 
past. The plan that seems to me best to adopt is to detach 
and remove any membrane that can be reached, and then to 
apply the local application. This plan is held by many 
most experienced men to be useless, or worse. It is harmful 
upon the ground that any injury to the mucous surfaces 
encourages the fresh formation of membrane. It is useless 
because the noxious germs composing the membrane have 
already passed beyond the reach of local applications to the 
lymphatics and bloodvessels beneath. Such reasoning does 
not convey conviction to my mind, and the want of success 
upon which it is founded is, as I have shown, not altogether 
surprising. It is advisable to apply our local applications 
as gently as possible. The healthy mucous membrane should 
be in all cases respected. But the little bleeding that ensues 
upon detaching a thick flake of perhaps fetid membrane can 
surely be of but little importance ; and supposing that the 
membrane forms again, things are not worse than they were 
before. Of local applications many have been recommended. 
I prefer a saturated solution of borax with soda, or boracic 
acid in glycerine, the solution being made by the aid of a 
water bath ; or a solution of permanganate of potassium, 
twenty grains to the ounce ; or a ten-grain to the ounce 
solution of quinine, made by the aid of hydrochloric acid, 
in equal parts of glycerine and water. These are not un- 

20 



23O THE DISEASES OF CHILDREN. 

pleasant, the borax or boracic acid least of all so, and are 

best applied by painting with a bent laryngeal camel-hair 
brush. I prefer this method, as I believe it to be more 
thorough than any other. But the af n can, if it be 

preferred, be made by means 01 the hand spray — the nozzle 
being placed upon the tongue between the teeth, or p. : , 
through Mr. East's ingenious funnelled tongue depressor, 
and the pumping continued for a few seconds. The appli- 
cation must be repeated at least every two or three hours, 
often every hour. Other things have been recommended, 
such as perchloride of iron in glycerine, sulphurous acid in 
glvcerine, solution of liq. sodae chlorinatae or chlorine water, 
carbolic acid, etc. These are all antiseptics or germicides, 
and are radical in their intention ; others are useful for dis- 
solving the membrane, and of these lime-water and bicar- 
bonate of sodium solution (20 grains to the ounce, used as 
spray, are at once effective and harmless. For the same 
object Dr. Hale White has proposed a solution of pepsin in 
glycerine, and this solution also has active solvent power. 
For internal administration a c ot potassium or 

iacum lozenge may be given every three or four hours, or 
the citrate of iron and quinia may be given in glycerine, or 
chlorate of potassium and perchloride of iron in equal parts 
of glycerine and water. 

[The following prescription, acting both locally and gene- 
rally, frequently produces excellent results : 



R. Quiniae Sulphatis, 



lloratis, . 

Tine. Fern Chloridi, 
Syrupi Zingiberis, 

r. . 



gr. xij. 



gr. xlviij. 

. . . . t-.-. 
.... rg. 

q. s. ad fjfiij. M. 
S. — - nful, dilut : h juts, for a child from 

ye its. 

Should the stomach revolt against quinine, either the sul- 
phate or bisulphate, in two to three grain doses, may be 



DIPHTHERIA. 23 I 

given in suppositories, every four or six hours, at the age of 
six years. In the preparation of these care must be taken 
to reduce the drug to an impalpable powder, lest local irri- 
tation be produced. 

Stimulants in free doses — as one teaspoonful of whiskey 
every hour — are called for in some instances.] 

Cases of this kind should have plenty of fresh air, but be 
kept warm in bed, and the air should be kept charged with 
a moist disinfectant vapor. One of the best is, I think, the 
following: creasqte. 5j, pulv. acaciae, oij. The gum and 
creasote are rubbed up together, and added to two ounces 
of lotio acidi carbolici (1 and 20). The whole is then put 
into a bronchitis kettle with a pint of water. A not un- 
pleasant vapor is given off, distinctly different from either 
creasote or carbolic acid. 

The food given must be of the strongest: milk, eggs, 
strong beef-tea, Brand's essence. If children refuse liquids, 
there is no particular objection to the administration of 
solids ; and for those who are difficult to tempt it may be 
advisable to try artificially digested foods, which are most 
temptingly administered in the form of jelly or blancmange. 
Wine also must in many cases be administered, and in large 
quantities; two or three ounces of brandy in the course of 
the twenty-four hours. In the worst cases it may be ad- 
visable to try enemata; but they are not borne long in chil- 
dren, as the rectum becomes irritable and expels them after 
one or two have been retained. Indeed, as I have elsewhere 
remarked, the failure of enemata has induced me to resort 
to the passage of a soft catheter along the nares into the 
oesophagus, and food has been introduced by this means 
into the stomach very satisfactorily. 

Tracheotomy. — If a child is choking, it is obviously right 
to give it the further chance which opening the windpipe 
offers : no one will dispute this. The chance appears to 



:x. 



vary in the experience of different physicians, but probably 
Trousseau's original estimate of his own cases — one recov- 
ery in five — is about the average all round. Still there is 
no little difficulty in deciding this question, for there is prob- 
ably no operation in surgery, if I may venture to say so, 
which requires so much the personal supervision of the sur- 
geon as tracheotomy, and I believe there can be few in which - 
the degree of hope which may be indulged depends so much 
upon the after treatment. But it is the custom of the advo- 
cates of operation to argue that the mortality after trache- 
otomy is so great because the operation is postponed till too 
late ; that the operation itself is not a serious one, but that 
it cannot be expected to succeed if performed when the dis- 
ease has extended down the trachea, and that if performed 
early more success would attend it. Now first of all let us 
clearly understand what this means. It means that the 
trachea is to be opened before there is any immediate risk 
to life, and this ; /different thing to an operation 

h is the only chance left of life. But there can be no 
objection to an early operation if no extra risks are entailed 
by it, or if any extra risk is compensated by advantage 
gained, such as, e.g., if by operating early the formation of 
membrane can be arrested. I would venture to dwell upon 
these alternatives, is I do not think they have been always 
well considered. Early operation has been defended chiefly 
upon the ground that the operation is not a serious one. 
Now I say that in diphtheria it is a serious operation. It is 
prima facie unreasonable to contend otherwise, if it be true, 
as many think, that even the membrane on the fauces should 
not be disturbed for fear of provoking fresh inflammation 
and formation of membrane ; and as a matter of fact, the 
operation of tracheotomy, when performed upon the diph- 
theritic child, is frequently followed by diffuse inflammation 
eilular tissue of the neck — the edges gape, and a 



DIPHTHERIA. 233 

large sloughy wound is formed, which becomes dry and 
fetid, and not unfrequently covered with membrane. But 
further, is it supposed that the mucous membrane of the 
trachea itself suffers no injury from the introduction of the 
tube ? The richness of the glandular and blood supply, 
and the sensitiveness of the mucous membrane to changes 
of temperature, make such a thing highly improbable, 
whilst it would be easy to show, in the clearest manner, 
by the evidence of the post-mortem room, that the operation 
itself, and the presence of a tube afterwards, are, in one way 
and another, fraught with danger. It is, in fact, my belief 
that the broncho-pneumonia, the purulent bronchitis, the 
excessive tracheitis, so often seen in fatal cases of diphtheria, 
are chargeable quite as much to the operation as to the 
original disease. The state of the trachea in fatal cases is 
not calculated to impress one favorably with the harmless- 
ness of tracheotomy ; but let that pass, for it may well be 
said that these are the hopeless cases, qua diphtheria. But 
even in others that do well the amount of mucus and muco- 
purulent discharge ejected from the tube, and the slowness 
with which this ceases, are sufficient to show that the mu- 
cous membrane of the trachea must in any case undergo 
grave alterations. . For these reasons, amongst others, early 
tracheotomy in diphtheria must be advocated, not from its 
harmlessness, but upon other grounds. But hitherto these 
other grounds have been little appealed to in practice. The 
operation has been performed ; if happily the membrane 
failed to spread — well, but no thanks to treatment; the 
operation relieved a symptom and temporized while the 
disease spent itself. If death resulted it was only to be ex- 
pected of the disease ; the operation has taken no share of 
the responsibility. But if, on the other hand, we resort to 
an operation not immediately necessary, in the hope that by 
so doing, some local measures may be adopted which will 



234 THE DISEASES OF CHILDREN. 

help to combat the formation of membrane, the operation 
has another basis upon which it may stand of a less assail- 
able nature. Upon this ground alone — that of the more 
thorough application of local remedies to the larynx — does 
an early operation admit of advocacy. Possibly on this 
ground the operation will yet justify itself and the additional 
risk which it necessitates be more than counterbalanced. 
It cannot be said that this is so at present ; and, although I 
would urge perseverance in local measures, I still think that 
the operation of opening the windpipe should be deferred to 
the latest possible limit. 

[Tracheotomy should not be too long delayed. It should 
be performed as soon as there are urgent symptoms, and every 
preparation for the operation should be made beforehand, 
that no valuable time may be lost during it. The symptoms 
demanding operation are increasing dyspnoea, supra-sternal 
depression, well-marked retraction of the scrobiculus cordis, 
and lividity about the face and finger tips.] 

When tracheotomy has been determined upon, the prin- 
ciple upon which success depends is to tamper with the tra- 
cheal mucous membrane as little as possible. To put a 
tube into the trachea and to leave it there, save for changing 
it occasionally, is but to exchange the risk of choking for 
the more deadly one of diffuse and ulcerative tracheitis. 
No doubt a certain sense of security is felt by the surgeon 
when a tube is safely in the throat, but it is dearly purchased 
for him by his patient, and the largest percentage of suc- 
cesses will certainly be procured by dispensing with the 
tube as much as possible. But this treatment cannot be 
carried out without a trained nurse who is equal to remov- 
ing and re-inserting the tube, and who is also possessed of 
sufficient self-command to meet the still greater emergency 
of not being able to re-introduce the tube, when it will be- 
come necessary to keep the wound open by forceps until 



DIPHTHERIA. 235 

assistance can be procured. With a nurse of this kind, and the 
frequent supervision of the surgeon, one cannot doubt for a 
moment that the stated mortality can be, and has been in 
the hands of individual operators, largely reduced. 

The operation itself is a surgical procedure, and it may 
perhaps be thought that I have no necessity and no right to 
speak upon that subject. Nevertheless, upon the principle 
that lookers-on see most of the game, I shall venture to add 
what seem to me hints of importance for its due perform- 
ance. 

The rules which I would lay down for the conduct of 
opening the windpipe, are these : The operation should be 
as high as possible (i) because it may be necessary to deal 
locally with the formation of membrane in the larynx by 
means of the aperture, and this can be more effectively done 
when the operation is high than when it is low; (2) because 
it is advisable to interfere as little as possible with the tra- 
cheal mucous membrane, and the connective tissue of the 
neck is less encroached upon in the incision. When the 
trachea is opened, the incision should be well separated by 
a dilator, and the parts thoroughly examined. This done, 
any membrane discovered either above or below it is to be 
removed gently by a soft feather, and if necessary, an appli- 
cation may then be made to the larynx of a solution of 
boracic acid or borax in glycerine, either by a feather or the 
spray. The opening must be kept as free as possible, and 
the interior of the windpipe tampered with as little as pos- 
sible. The expulsion* of membrane is thus favored, and the 
risk of extension of inflammation down the trachea is re- 
duced to its minimum. To accomplish these objects some 
instrument, such as Golding-Bird's dilator, or Parker's auto- 
matic retractor, seems to me best in principle, although per- 
haps a metal tube as large as possible is more available for 
practice . This must be inserted for the first twenty-four hours . 



236 THE DISEASES OF CHILDREN. 

After this our aim is to do without any dilator or tube as much 
as possible. By this time any inequalites upon the sides of 
the incision which would be likely to hinder the easy re- 
introduction of the tube will have become sealed by lymph. 
Whatever the instrument employed it should be removed, 
the child being closely watched, so that it may be re-in- 
serted when necessary. The time for which the dilator can 
be removed will vary much. Sometimes not more than ten 
minutes can be allowed — sometimes half an hour, or an 
hour, or more : the more the better. Some cases have been 
treated successfully throughout without any tube, and I sus- 
pect this could be done more often and with much advantage 
to the patient. The tube is to be taken out several times 
daily, and kept out as long as possible, and after a day or 
two the metal tube is to be replaced by one of Mr. Morrant 
Baker's soft india-rubber tubes as short as possible. When 
the edges of the wound have consolidated, the curve of the 
tube may be removed, leaving a straight stump long enough 
to reach from the surface through the cedematous tissues to 
the trachea, but not longer. So far as the nature of the 
material is concerned, I believe it would be better to insert 
a soft rubber tube at once, but the objection to this is that 
the bore of these is smaller than that of the metal tubes, and 
for the first day or two it is of paramount importance that 
the aperture should be as free as possible. When the tube 
is removed or replaced, the opportunity must be taken, if it 
be judged necessary, for applying the boracic solution to 
the larynx. This should be done regularly ; the trachea 
should only be treated in similar fashion if there be evidence 
that the membrane is extending downwards. The applica- 
tion may be made by a feather or a laryngeal brush, or by 
a piece of sponge or cotton wool twisted into a loop of wire. 
If necessary a spray can be applied to larynx or trachea 
through the opening. I have no great affection for feather- 



DIPHTHERIA. 



237 



ing the trachea for the removal of membrane, and probably 
a free aperture best effects its expulsion ; but one of the risks 
attaching to the operation is the loss of expiratory power, 
which results from opening the trachea below the larynx, 
and this makes it necessary to be ever on the alert to re- 
move membrane either in this way or by the tracheal forceps, 
which must always be ready to hand. 

I must further add as regards the final removal of the tube, 
that those only who have had experience of such cases know 
how difficult this often is. What the exact conditions in 
the trachea or larynx may be that render it so are difficult 
to state, but it is often many days, and sometimes weeks, 
before the tube can be altogether dispensed with. Perhaps 
the child will breathe well by day and badly by night, or 
will go without the tube completely for three or four hours 
and then have dyspnoea. In all these cases the short tube 
should, if possible, be worn, and the external aperture should 
be kept plugged as much as possible so as to compel breath- 
ing by the natural passages. 

The creasote vapor has already been advised, and plenty 
of fresh warm air. Many recommend a steam tent, but, 
provided the cot is well fumigated by the moist vapor, this 
is hardly necessary, and it often makes the child hot and 
restless. 

There is yet the treatment of diphtheritic paralysis to be 
considered, and this may be both preventive and curative. 
It is of the utmost importance to remember that diphtheria 
is a disease which leads to great anaemia — great exhaustion; 
and it is the opinion of many that if after diphtheria the 
child be confined to bed, kept quite free from excitement, 
and fed frequently, and so treated until the nutrition has been 
in some measure restored, and the anaemia curtailed, paraly- 
sis will but seldom occur. There can be no doubt that to 
be up and about in the early days of convalescence, feeling 



238 THE DISEASES OF CHILDREN. 

ill, but without anything definite the matter, is one of the 
surest incentives to its onset, and it is also to be remembered 
that, like the albuminuria of scarlatina, the paralysis after 
diphtheria may follow such cases of indefinite disease, as the 
malaise and slight sore throats which so often run through 
a household when one of its members is attacked with the 
pronounced disease. 

When paralysis has come about, the same rules apply ; 
perfect rest in bed is the first necessity, together with the 
most nourishing food. This must be given at frequent inter- 
vals, and it is well to remember that in the paralysis of the 
throat solids are often better swallowed than liquids. It 
may be necessary to feed by means of a tube passed into 
the stomach, and probably the nasal tube will be more easy 
of application than the oral. Enemata may be also given 
and, in addition to the food, stimulants are valuable, and 
maltine and cream are good additions to the food. The 
greatest care and patience is requisite in feeding these cases 
lest they choke, or food passes into the larynx and trachea 
and sets up a broncho-pneumonia. Most of the cases of 
localized faucial paralysis recover but slowly, and a great 
deal of inconvenience may be experienced for months — 
sometimes in swallowing, sometimes by difficulties in pho- 
nation — but those where the affection is general are always 
tedious and often dangerous. The heart suffers and the 
respiratory muscles also ; the one becoming dilated, the 
others, by their sluggish and imperfect action, leading to 
collections of mucus in the bronchial tubes and so to bron- 
cho-pneumonia. These cases must be fed as others; iron 
and arsenic must be administered, and the muscular system 
must be renovated by the movements of shampooing and 
by electricity. In paralysis of the heart in its worst forms 
the sudden fatal issue precludes all treatment; but a careful 
watch upon the heart should be kept in all these cases for 



DIPHTHERIA. 



239 



the earliest indications of dilatation of the ventricles. A 
careful administration of digitalis, or belladonna and iron, 
and stimulants may, in these cases, sometimes be attended 
with successful results. 

[Strychnia in properly proportioned doses, either alone or 
combined with iron, should be employed in cases of pa- 
ralysis.] 



24O THE DISEASES OF CHILDREN. 



CHAPTER XIV. 

VARICELLA. 

Varicella. — The chief interest of chicken-pox lies in its 
resemblance to small-pox, and in the suggestions which 
come out of this resemblance. The relation of vaccina to 
variola and the different behavior of the latter when intro- 
duced by inoculation to that which it shows when operating 
upon virgin soil, under conditions of introduction, so to 
speak, of its own choosing, show how liable is variola to 
undergo modification. And when further we bear in mind 
the many points of resemblance which modified variola bears 
to varicella, the question irresistibly presents itself, is vari- 
cella modified small-pox ? To this the answer must be — No. 
For many reasons, but for this one above others — conclusive 
as it is considered for all exanthems — that varicella and va- 
riola may both occur within a short time of one another in 
the same person, and pursue an unmodified course. One 
of the most striking cases of this kind is recorded by Dr. 
Sharkey in the Lancet, vol. ii., 1877, p. 47. A boy, aged 
five, under Dr. Bristow, was admitted with varicella out upon 
him. Variola was rife at that time, and existed in the block 
where the child was warded ; he was on this account vacci- 
nated the third day after his admissioii, and took very well. 
Ten days after admission, the eighth day from vaccination, 
he became very ill, and the next day the variolous eruption 
appeared. Varicella does not therefore protect from variola, 
nor does vaccina protect from varicella, and the germs are 
distinct. 

Incubation. — This is variously stated to last from eight 



VARICELLA. 



241 



to sixteen days. Dr. Dukes, from some careful observa- 
tions made at Rugby, makes it as long as fourteen to nine- 
teen days, the shortest incubation in fifteen cases being 
thirteen to fourteen days in one case, fourteen in two, four- 
teen or fifteen in one, fourteen to sixteen in two, fifteen in 
three, and the remainder more. It is attended by no defi- 
nite symptoms ; but there may be slight malaise for a day 
or two before the outbreak of the eruption. 

Eruptive Stage is generally associated with more or less 
pyrexia, loss of appetite and langor ; but the amount of 
constitutional disturbance may be, and usually is, very slight 
indeed. In unhealthy children the eruption may be copious 
and the resulting sores lingering in their course, and in such 
the illness may be considerable, and even followed by per- 
sistent anaemia, discharge from the ear, or some enlargement 
of glands ; but this is rather an outcome reserved for the 
squalid and forlorn than for the child of the well-to-do. It 
is also stated, and this is interesting when we remember the 
mortality which attends measles in native races, that the 
mortality is sometimes high in India amongst the ill-fed 
and badly clothed children of the native population. The 
eruption cosists of oval or globular vesicles containing 
opalescent contents situated upon a slightly inflamed base. 
The vesicles commence as a small red papule, the vesicle 
forming within a very few hours, whilst the amount of 
inflammation around it constitutes a measure of the severity 
of the disease and of the condition of the patient. In many 
cases there is no areola round the vesicle ; a small pearly 
bleb rises from an almost natural skin, and the appearance 
of the child suggests that it has been exposed to a shower 
of boiling water. In severe cases the zone of injection 
around is vivid and considerable. The eruption comes out 
in crops, one crop quickly succeeding another, mostly on 
the back and abdomen, but -also found on the face, scalp, 



242 



THE DISEASES OF CHILDREN. 



and other parts, more rarely in the mouth. The vesicles 
form rapidly; they contain alkaline serum, which becomes 
a little turbid, in some cases purulent. In ordinary cases 
the vesicles shrivel within a day or two and leave a small 
dry scab. This falls off in another day or so and leaves 
behind a small pigmented stain, and occasionally a slight 
scar. Mr. Hutchinson thinks that scars are not uncommon 
if carefully looked for ; but this depends much upon the 
extent of local change. If the vesicles are rubbed or ex- 
coriated in any way — or if the vesicle ulcerates, as it may 
sometimes do, these scars will be found, but not otherwise. 
The vesicles come out in crops, occasionally lasting for six 
or eight days, but usually exhausting the disease within 
three or four days, or even sooner. 

The disease occurs in quite young infants. Gee gives a 
table of 727 cases from the Ormond Street Hospital, with 
this result : 



Under 


I month, 






2 


Under 


4 years, 


100 


tt 


2 months, 






8 


<( 


5 " • 


96 


" 


3 " 






13 


" 


6 " . . 


58 


" 


6 " 






57 


tt 


7 " . 


30 


a 


12 " 






97 


tt 


8 " . . 


29 


" 


18 " 






62 


tt 


9 " • 


10 


" 


2 years, 






75 


" 


10 " . . 


5 


" 


3 " 






78 


(( 


12 " . . 


7 



It is not known to recur, and has no complications and 
almost no sequelae. It may, however, be stated that the 
vesicles are attended with a good deal of irritation, and in 
the unhealthy children of the hospital out-patient room, it 
is not uncommon to find somewhat persistent superficial 
ulcers, perhaps beneath scabs, for some time after the out- 
break of the varicella. But when this is the case, the stu- 
dent should have it in mind that the original malady may 
have been pemphigus and not varicella at all. 



VARICELLA. 



243 



Diagnosis. — Modified variola causes the most difficulty. 
It will be well to bear in mind that varicella has no prodro- 
mal fever, that the vesicles are not umbilicated, and collapse 
at once when pricked — in other words, they are simple, not 
multilocular ; and that the eruption comes out in crops, 
and therefore exhibits stages upon the skin ; while variola 
appears at once. 

[With variola, varicella stands contrasted by its brief in- 
vasion period, the short duration of its initial fever, the 
absence of secondary pyrexia, the difference in the position 
at which the surface lesion first appears, the larger size and 
softness of the papules and the rapid transition of the phases 
of the eruption. 

There are several features of small-pox, usually considered 
to be important distinctions between it and chicken-pox, that 
are of little diagnostic value, because, practically, they are 
common to both diseases. These are the appearance of the 
eruption on the scalp, its presence on the visible mucous 
membranes, umbilication of the vesicles, and pitting* 

I have often seen the eruption of varicella on the scalp, 
and in the majority of my cases a varying number of pseudo- 
membranous points were present on the mucous membrane 
of the cheeks and palate, differing from those of variola 
only by being larger and more yellow in color. Again, 
the vesicles are frequently umbilicated; this occurs only 
in those that begin to desiccate in the centre, and on close 
inspection minute crusts can be detected in this position. 
Both the cause and appearance differ, therefore, from the 
variolous umbilication, but the likeness is close enough to 
confuse a superficial observer. 

Pitting, too, occurs where large vesicles are accidentally 
broken by scratching. It is usually seen on the face, and 
the scars which rarely number more than three or four are 
broader, shallower and smoother than those of variola.] 



244 THE DISEASES OF CHILDREN. 

Pemphigus can hardly cause any difficulties, if the case 
be thoroughly inquired into, unless, indeed, we have to do 
with cases such as have been described: (i) by Mr. 
Hutchinson as persistent or relapsing varicella — where 
the disease may last as long as a month ; (2) by Trousseau, 
in which biebs like those of pemphigus come during fifteen 
to forty days, causing ulcerations like those of pemphigus, 
and which continue for six or eight weeks. 

Varicella has also occasionally to be distinguished from 
vesicular or pustular rashes following upon vaccination. 
Hebra says of them, that they resemble varicella. They 
are not very common. 

Sequelae. — Most writers would be inclined to say that 
there are no sequelae of varicella ; but superficial ecthyma- 
tous-looking sores are by no means uncommon in the 
hospital out-patient room. Mr. Hutchinson alludes fully 
to this condition, and how it may resemble pemphigus. 
Under the term varricella prurigo, adopted by him, are 
included not only the clearly vesicular rashes, which con- 
tinue after varicella, but also many of those papular prurigos 
which have hitherto been called lichen urticatus, lichen 
strophulus, etc. Mr. Hutchinson points out that many of 
these cases called lichen show abortive vesicles ; that they 
occur on the palms and soles, where no lichen can — seeing 
that it is a disease of the hair-follicles ; and that there is, in 
some cases at all events, a history, if not of origination in a 
recognized varicella, yet at any rate of definite onset at some 
particular date. Mr. Hutchinson seems, however, to adopt 
a view which I have long believed, that in these cases it is 
hardly so much the disease which is at fault as the child ; it 
is the fact of the occurrence of varicella — a disease which is 
apt to start a chronic itching — in a pruriginous skin (not 
uncommonly an inherited weakness), which entails such dis- 
agreeable results upon the child. 



VARICELLA. 



245 



Treatment. — Varicella very seldom requires any — at the 
most some simple saline, a mild aperient, and a little vase- 
line or ung. metallorum to relieve the local irritation of par- 
ticular spots, are all that can be necessary. 

Vaccina. — Of this as a disease it is hardly necessary to 
speak, so little in the majority of cases does it affect the 
child's health. But this much may be said, that amongst 
the lower orders a large number of cutaneous affections are 
attributed to vaccination. If assertions of this kind are 
traced to their source, many have no foundation in fact. 
Yet some have — and it is well not to discredit such tales too 
readily. It can hardly be that the introduction of a material 
such as vaccine into the system never proves detrimental, 
and unquestionably, from time to time, vaccination is fol- 
lowed by various forms of cutaneous eruption. The risk of 
such an occurrence is as little to the individual as the gain 
to the community is great from the practice; but the occa- 
sional occurrence of such a result is an incentive to the 
exercise of the most scrupulous care in vaccinating only 
such infants as appear healthy, and in selecting only such 
lymph as is absolutely pure. 

Much has been heard of late of the introduction of the 
syphilitic virus by means of vaccine, and I cannot doubt that 
such a thing may occasionally happen, but its exceeding 
rarity, while it should serve to ensure the strictest precau- 
tions, may very well be used as an argument in favor of 
vaccination rather than one against it. 

[A short synopsis of the symptoms of the typical vaccine 
disease seems proper. 

Local Symptoms and Course of the Sore, — Usually on the 
third day a small hardened nodule of faint-red color appears 
at the seat of introduction of the virus. A serous exudation 
now raises the cuticle, and a vesicle is formed which by the 
sixth day begins to be depressed in the centre, or umbili- 



246 THE DISEASES OF CHILDREN. 

cated, and at the same time is surrounded by a narrow ring 
of inflammation. The vesicle increases in size, and reaches 
perfection by the eighth or ninth day ; it then projects above 
the surrounding surface, has a dull white color, and is about 
one-third of an inch in diameter. The narrow inflamma- 
tory zone has now extended so as to become a broad areola 
as much as two inches in breadth, of a scarlet, rose or dark- 
red hue, the color gradually fading from the centre to the 
periphery where it shades into that of the normal skin. 
Coincident with the surface inflammation the subjacent con- 
nective tissue becomes infiltrated, hard, tender and painful. 
By the tenth day the inflammatory symptoms have reached 
their height. The areola now rapidly fades and the vesicle 
loses the pearly appearance — pus taking the place of lymph 
and giving its characteristic color to the sore. By the four- 
teenth day the inflammation has subsided, the pus has 
become inspissated and the crust begins to form. This be- 
comes harder and darker in color, and falls by the end of 
the third week. The resultant scar is of a deep red or 
purple color, but in the course of from three months to a 
year should become smaller in diameter and present a 
smooth shining surface marked by pin-point depressions or 
radiating lines. 

General Symptoms are seldom present before the eighth 
day, when the child may become fretful, with fever, disturbed 
sleep, restlessness and partial anorexia. 

Vaccination, — The introduction of vaccine virus into the 
system is effected in several ways — by incisions or scarifi- 
cation, puncture and abrasion. 

The virus employed may be contained either in lymph 
directly from the vesicle, the dried vaccine crust powdered 
and suspended in water, or the lymph from cow-pox. 

Scarification consists in making four or five parallel inci- 
sions about a line apart and intersecting these with the same 



VARICELLA. 



247 



number at right angles. Should blood flow one must wait 
till this stops and there is but an oozing of serum, before the 
virus is rubbed in. 

The puncture method consists in making a horizontal 
pocket in the true derm with the point of a lancet, in the 
groove of which is the virus. The puncture is then closed 
with isinglass plaster. 

Abrasion is the preferable method. The skin is made 
tense between the thumb and forefinger of the left hand, 
while with a gum lancet, which has no points to catch or 
cut the skin, the epidermis is quickly removed by a rapid 
but gentle scraping movement until serum slightly tinged 
with blood exudes from the true derm. The virus is then 
applied. Whatever form may be used must be well rubbed 
in and the part left exposed until the exuded serum, which 
contains the bulk of the virus, dries. 

Vaccinating from arm to arm, taking the lymph directly 
from the vesicle, is not very frequently done now, and is not to 
be recommended, though convenient in public institutions, 
where there are many individuals to be vaccinated at once. 
Care should be taken that no blood is mixed with the lymph. 

The crust is still frequently employed. The central part 
only should be made use of, as the margin is apt to contain 
blood and may be the means of conveying disease. The 
part employed should be rubbed into an impalpable powder 
and dissolved in water. It is claimed by some that humanized 
virus takes a day sooner than bovine virus. This may be of 
importance in epidemics and should be remembered. 

Fresh bovine lymph on quills or ivory points can be ob- 
tained at any time in almost all large cities, and is much 
to be preferred as it does away with the possibility of the 
patient becoming inoculated with any foreign poison. When 
applied the points or quills are moistened with clean water 
and the virus is well rubbed into the abrasion. 



248 THE DISEASES OF CHILDREN. 

The age considered most suitable to perform the operation 
in infants is from the fourth to the twelfth month, though 
it is very common to vaccinate about the fourth week before 
the monthly nurse is discharged. 

It seems important that the operation be performed 
early, as statistics show that in England nearly one-fourth 
of the mortality from small-pox occurs during the first 
year of life. Should an epidemic be prevalent the child 
should be vaccinated within the first twenty-four hours. 
The point selected for inoculation is usually the left arm, 
over the insertion of the deltoid muscle, but the leg is to be 
preferred, the choice position being beneath the knee and on 
the outside of the limb, just below the junction of the tibia 
and fibula. In this site the sore is less apt to be irritated 
than at any other part of the body; there is no tight-fitting 
garment as there is about the arm, the diaper does not come 
within two inches of it, and besides the lymphatics are less 
apt to sympathize. The part, too, is easy to get at, and where 
the abrasion method is employed the operation can frequently 
be completed on a sleeping child without its being aroused. 
The number of points of insertion do not seem important 
so that the system be thoroughly impressed. Of this we 
can feel pretty sure from the character of the sore and the 
resultant scar. If later in life revaccination is performed, 
almost a positive immunity from small-pox can be as- 
sured.] 



^ 



MUMPS. 



249 



CHAPTER XV. 



MUMPS, 



Parotitis (Mumps). — Inflammation of the parotid gland 
occurs under two sets of circumstances. In the one, it is 
secondary to typhoid fever, scarlatina, measles, etc., when 
it usually ends in suppuration ; in the other, it is a primary, 
acute, epidemic and contagious disorder. With the latter 
we have alone to do now. Mumps appears to be looked at 
askance by writers on specific fevers. Like whooping- 
cough it has such definite local symptoms that there is reason 
for treating of it as a disease of the part which is specially 
concerned. But, inasmuch as it occurs in epidemics, is 
very contagious, whilst a second attack is exceedingly rare, 
there seems very little ground for excluding it from specific 
diseases. 

Incubation. — Fourteen to twenty-five days, according to 
Dr. Dukes' observations, which are the most complete that 
I know of. He gives fifty-seven cases of mumps ; fifteen of 
these were not available for the purpose of drawing conclu- 
sions. In the other forty-two the incubating period was 
from sixteen to twenty days in thirty, and possibly in thirty- 
four. Like most other specific fevers, the period of incuba- 
tion certainly varies. In a family which I observed myself, 
a little girl incubated for fourteen days after coming in con- 
tact with a child with mumps. The next child took it 
twenty-one days later, and the third twenty-one days later 
still. Henoch gives the stage of incubation as about four- 
teen days ; but I think this is too short. Ringer says eight 
to twenty-two days. 



25O . THE DISEASES OF CHILDREN. 

Symptoms of Attack. — The disease is attended with con- 
siderable malaise rather than with downright illness. The 
child looks very pale, ancj — on one side or the other, per- 
haps on both, often commencing on one side (the left, so it 
is said, more commonly), and extending to the other — there 
is a tender swelling which occupies the parotid region be- 
hind the angle of the jaw, and spreads over the side of the 
face in the situation of the socia parotidis. Generally, the 
color of the skin is not altered; but occasionally there may 
be some redness over the parotid. There is a dull, aching 
pain when the masticatory muscles are moved. The tem- 
perature may be a little raised, but in many cases it remains 
normal. The swelling lasts for four or five days, and then 
gradually subsides. As regards the constitutional disturb- 
ance, there is some variety. The fever may be considerable 
(103 ) for a short time; Dr. Gee has recorded one case of 
onset with convulsions, and there may be some delirium at 
night. As regards the swelling, it is not always by any 
means confined to the parotid ; it extends to the submaxillary 
gland, and also to the cervical lymphatic glands, and may 
sometimes even be confined to the latter, in which case the 
disease is likely to be mistaken. Occasionally the swelling 
is so great as to extend from one side to the other in a huge 
continuous double chin. When the disease is severe, the 
difficulty of deglutition is considerable, and, the child breath- 
ing with its mouth open, the tongue may thus become brown 
and dry. This is a point which it is important to remember 
for the symptom is one which might otherwise lead us to 
regard the case with greater anxiety than need be. 

The duration of the disease is very variable; five or six 
days appears to be about the usual limit ; its course, how- 
ever, maybe protracted, for it sometimes happens that when 
the swelling has subsided on one side, it recommences on 



MUMPS. 



251 



the other, and in this manner ten or fourteen days may be 
occupied. 

Complications. — Chief of these is the tendency, a rare 
one, in males to the occurrence of orchitis. It is often spoken 
of as a metastasis ; and I do not know that there is any ob- 
jection to the term, inasmuch as the testis usually becomes 
affected as the parotid swelling subsides, although the two 
regions may be affected concurrently. Dr. Dukes gives 
twelve cases in boys ; in six the orchitis began on the seventh 
day; in four on the eighth; with one on the ninth; and 
one on the first. The body of the testis becomes suddenly 
swollen and intensely painful, and fluid often collects in the 
tunica vaginalis. The accompanying constitutional disturb- 
ance is generally severe, there being high fever and perhaps 
considerable delirium. All writers record the occasional 
occurrence also of an homologous affection of ovaries and 
mammae ; but I suspect that this is one of the statements 
which is copied from book to book, and is far more imagi- 
nary than real. I cannot find any notes of such cases. The 
occurrence of orchitis in mumps is rare ; indeed, it is a dis- 
ease of adolescents rather than of children. Dr. West has 
no personal experience of it, and Dr. Dukes considers that 
it comes only to those who have arrived at or beyond the 
age of puberty. I have, however, seen a very severe case in 
a boy of about twelve. He came under my own care some 
years ago. 

The orchitis usually subsides within a few days; but it 
may, on the other hand, lead to persistent hydrocele and 
atrophy of the testis. 

[The appearance of orchitis at the date on which the par- 
otitis naturally begins to disappear, tends to support Nie- 
meyer's view, that the two affections are in reality due to 
the same cause, and that there is no true transference of 
inflammation from the parotid to the testicle. The right 



252 THE DISEASES OF CHILDREN. 

testicle is more frequently affected. The inflammation and 
swelling increase for from three to six days, after which 
resolution is rapid and generally complete by the end of the 
second week. The general symptoms are somewhat more 
intense than during the mumps, and, if the orchitis be bi- 
lateral, they are still more severe, and the course of the dis- 
ease is slightly prolonged.] 

Meningitis is another complication described as occurring 
but which must be very rare. Possibly a similar remark 
applies to this as to the ovaritis and mastitis ; and it is not 
unlikely, I think, that the severe delirium which occasionally 
presents itself in the course of the testicular — and even some- 
times of the parotid — inflammation may by some have been 
considered evidence of meningeal inflammation. 

Sequelae. — A chronic induration of the gland is sometimes 
left behind after the attack ; but it is of little consequence, 
and usually cures itself in the lapse of time. 

Suppuration of the gland is an occasional but rare sequela. 

iEtiology. — Although there are some who doubt it, the 
infectious nature of mumps seems to me indisputable. Why 
I think so, I have already stated. It is now only necessary 
to add that, although the disease is communicated by 
germs, it is not necessary to take any special precautions 
for the isolation of the affected children. The disease is 
so mild and so free from sequelae, that it can seldom be 
worth while to enforce any strict quarantine. Delicate chil- 
dren should naturally be protected as far as may be, and 
possibly boys when they are attaining to the age of puberty. 
It is certainly advisable to avoid all risk of orchitis. 

Morbid Anatomy. — Practically none. Virchow has con- 
tended that the disease is a catarrhal affection of the ducts 
of the parotid gland, and Bamberger states the whole gland 
to be enlarged, red, and oedematous from interstitial exuda- 



MUMPS. 253 

tion. This is, indeed, highly probable, but facts to corrobo- 
rate it are very few. 

[The exact pathological lesion is obscure, on account of 
the rarity of opportunity for post-mortem examination. 
Foerster states that the affected gland first becomes hyper- 
aemic, and is then the seat of serous exudation. It is red- 
dened, swollen, and on section presents a uniform, flesh-like, 
moist appearance, in place of the ordinary granular surface. 
The tumor is often greatly increased in size by a simultaneous 
serous infiltration of the periglandular connective tissue ; 
occasionally, this tissue alone is involved. The rapid and 
complete disappearance of the glandular swelling by the 
process of resolution favors this view.] 

Diagnosis. — I can imagine that in young children the 
sudden and rapid swelling of the cervical glands from scar- 
latinal or diphtheritic poison might cause some doubt. But 
the extreme illness in the one and the less serious state in 
the other will ere long settle the doubt. On the other hand, 
the fact that mumps may show itself as an affection of the 
submaxillary gland or even of the cervical lymphatic glands, 
and leave the parotid untouched, though such cases are 
rare, is worth remembering. Lastly, the occurrence of sup- 
puration should make one suspect and examine for some 
septic state other than that which hypothetically we sup- 
pose to be present in an attack of uncomplicated mumps. 

Treatment. — It often happens that no medicinal treatment 
is required. The child is kept warm in one room, and its 
diet is made to conform to its inability to masticate — to con- 
sist, that is to say, of milk, broth, jellies and blanc-mange. 
Should there be much fever, a drink maybe made of barley- 
water, to which fifteen or twenty grains of nitrate of potas- 
sium, and the same quantity of bitartrate, have been added 
to the pint. 

The local pain may be relieved by warm moist applica- 



254 THE DISEASES OF CHILDREN. 

tions, such as spongio-piline wrung out of hot water, or by 
lint soaked in warm water and covered with oil-silk. Chlo- 
roform or belladonna may be sprinkled on these, if neces- 
sary. Small doses of Dover's powder are also sometimes 
necessary. If the fever is severe, a drop of tincture of aco- 
nite may be given every hour for a few hours. 

The child is to be kept indoors for nine or ten days, and 
some tonic, such as Parrish's food, may be given afterwards. 
In older children of the male sex and adolescents, particu- 
larly the latter — for the older the boy the more likely is 
there to be orchitis — the child must be kept in bed for eight 
or nine days, and the temperature carefully watched. 9 Dr. 
Dukes has found that a rise of temperature is a good 
warning of the occurrence of this complication, and that 
the early application of poultices to the part mitigates the 
pain and lessens the severity of the affection. 

It has been asserted of late that jaborandi and its alkaloid 
pilocarpine have the power of arresting mumps if given suf- 
ficiently early. I have not had any personal experience of 
this ; but it is worth a trial, always remembering that pilocar- 
pine in children has sometimes acted as a powerful depres- 
sant, and should therefore be given with caution in the case 
of young children. I have given it in acute nephritis to the 
extent of one-fifteenth up to one-tenth of a grain as a subcu- 
taneous injection in children of ten and twelve years of age, 
and from the slight effect produced by the lesser dose this 
might safely be given to children of eight or six years. 

In the violent delirium which occasionally happens, I 
should be disposed to trust to saline aperients and warm 
baths. 

The orchitis requires plenty of warmth in the way of fo- 
mentations and baths, while the fever is treated either by 
aconite or saline diaphoretics. The urgent symptoms are 
not usually of any duration. 



WHOOPING-COUGH. 255 



CHAPTER XVI. 

WHOOPING-COUGH. 

Pertussis. — I shall complete the specific diseases inci- 
dental to childhood with an account of pertussis. ' Like 
mumps, it is always a question with writers whether this 
disease shall be placed with specific diseases or with those 
affecting the parts or organs with which the symptoms more 
particularly concern themselves ; but surely, if the disease is 
specific and possesses infective properties, the most impor- 
tant feature of the disease as regards the community is its 
specific nature — as regards the individual only, can the local 
symptoms claim priority. Since, therefore, the well-being 
of the community is of the first importance, pertussis, I think, 
most properly groups with those other diseases having con- 
tagious properties ; and, indeed, more fitly does it take this 
place than some others, for next to scarlatina it has the 
highest mortality of all the diseases of children. 

Incubation. — I have but few data of my own from which 
to fix the period of incubation — in a family of two sisters it 
appeared to be eight days, the one being exposed to infection, 
and a cough beginning eight days after, the other following 
suit eight days later — it is stated to be from four days to a 
fortnight. Dr. Murchison quotes three cases upon the au- 
thority of Dr. Bristowe, which are almost free from the 
possibility of error, and which give a period of incubation of 
fourteen days.* These cases are so well told, and the infor- 
mation is so precise, that I quote them as they are reported : 

* Observations on the Period of Incubation of Scarlet Fever, and of some 
other Diseases : " Trans. Clin. Soc," vol. xi., p. 238, etc. 



256 THE DISEASES OF CHILDREN. 

u In the winter of 1874-5, Dr. B.'s three youngest chil- 
dren, owing to having suffered from severe ' colds ' in the 
previous autumn, were kept in the house in London from 
the early part of December until May, when the following 
occurrence took place : They were then in perfectly good 
health, and for several months had seen no children nor 
visitors of any sort. But at that time some nephews and 
nieces of Dr. B. were ill at Sydenham with whooping-cough. 
On Saturday Dr. and Mrs. B. went to dine with his mother, 
who also resided at Sydenham Hill; and, on arriving, they 
found the eldest boy of the family referred to living with her. 
He had hitherto escaped the disease, and was living with his 
grandmother in the hope that he might escape it altogether; 
but on this very Saturday he had, for the first time, a con- 
stant troublesome cough. Mrs. B., being afraid on account 
of her own children, and believing that the boy was in the 
early stage of whooping-cough, did all she could to avoid 
him ; but he clung to her the whole evening, climbing on 
her knee, and coughing and sneezing over her. When she 
got home at night she took off her dress and laid it over an 
ottoman under a window in the dressing-room, intending 
next morning to have it hung out in the open air. Unfor- 
tunately, however, the eldest of the three children referred 
to came into the dressing-room early next morning, and 
began playing at the window over the dress. As soon as 
this was noticed she was sent away, and the dress was car- 
ried out of doors. Exactly thirteen days afterwards, on the 
Saturday, this little girl appeared to have caught a bad cold, 
and ten days later she began to whoop. The two youngest 
children caught the disease from her, and both sickened 
about a fortnight after she first showed signs of illness. The 
seven other children in the family escaped, but they had 
had whooping-cough before. " 

Probably here, as in other infective diseases, the incubative 



WHOOPING-COUGH. 257 

stage is a variable one, depending upon the conditions, both 
atmospheric and individual, under which the poison or germ 
is cultivated. 

Symptoms. — The disease has almost always been de- 
scribed as one of three stages, but there is no true third 
stage. There is a primary stage of catarrh and fever, and a 
second of the paroxysmal cough ; but for a third, it is neces- 
sary to fix an arbitrary limit where the disease does not 
define any. The distinction between the two stages is of 
importance, not only because of its clear definition, but 
because the remedies applicable in the second stage are 
harmful in the first. 

In the first stage, which lasts a week or ten days, the child 
is poorly, with moderate pyrexia and a hoarse, dry cough, 
sometimes with a peculiarity of timbre which has been called 
ringing. As with other febrile conditions, the child maybe 
pretty well during the day, with good appetite, or have its . 
fits of fretfulness and cough, with loss of appetite. Probably 
the more or less of these symptoms depends upon the extent 
to which the fever runs. Auscultation at this stage usually 
reveals more or less bronchitis of the larger tubes, indicated 
by moist and dry bronchial rales, but there is little or no 
visible secretion from the bronchial tubes. As the catarrhal 
stage proceeds, the cough becomes more noisy and parox- 
ysmal, with nocturnal exacerbations, and the face a little 
full-looking with the eyes suffused, an appearance which to 
a careful observer may suggest what is coming. The whoop, 
the characteristic of the second stage, appears towards the 
end of the second week. As I have watched it mostly in 
severe cases, and with the child in bed, the onset of a par- 
oxysm has been quite sudden, a short series of rapid expi- 
ratory coughs ; but, should the child be up and about, it 
often becomes restless for some few seconds or minutes 
before, and may even run to its nurse or mother for support. 



258 THE DISEASES OF CHILDREN. 

But, from some observations which Dr. Newnham was kind 
enough to make for me in the whooping-cough ward of the 
Evelina Hospital, it appears that in some it begins thus, and 
in others with a deep inspiration. In either case the first 
expiratory part is short, and followed by a short whoop, to 
be quickly succeeded by a longer series of similar short 
expiratory efforts to those at the onset, and a second and 
longer whoop, when the paroxysms may be over, or a third 
and a fourth may succeed, until the child is fairly exhausted. 
The paroxysm, short or long, terminates by a flatulent eruc- 
tation and vomiting — a quantity of stringy mucus and food 
being ejected, often mixed with a little bright blood. The 
frequent repetition of the cough produces, in many cases, a 
characteristic appearance of face, which cannot be mistaken; 
the features are swollen or puffy, and dusky in color, not 
unlike, so far as the tinge is concerned, the aspect of a case 
of typhus. The eyes are watery-looking, and dusky in like 
manner, an appearance due, as is the color of the skin, to 
numerous minute ecchymoses or congestions of the smaller 
capillaries. In many cases there are extravasations of blood 
beneath the conjunctiva, which, of course, hardly admit of 
mistake. If examined during this stage, the chest has little 
to tell, provided there is no broncho-pneumonia — a few 
rales, dry or moist, may be heard here and there, nothing 
more. The spasmodic stage of whooping-cough has no 
definite duration, and varies much in intensity. In severe 
cases there may be twenty to thirty paroxysms in the course 
of the twenty-four hours, or even more. At the Evelina 
Hospital, where all cases are recorded upon a chart, it is 
found that some paroxysms are accompanied by a whoop ; 
some are not ; and that sometimes one, sometimes the other, 
kind predominate. A typical case, one would suppose, 
should show an onset of the paroxysms without whoop, 
gradually lessening in number; paroxysms with whoop to 



WHOOPING-COUGH. 259 

replace them ; these again gradually declining and being 
replaced by a gradually lessening paroxysmal cough without 
whoop. But, as a matter of fact, it can hardly be said that 
this is so, the varieties are so many. Very young children 
often do not whoop. It is sufficient to know that they have 
fits of coughing, followed by sickness, and usually with some 
puffiness under the eyes. Children who are very ill with 
broncho-pneumonia often do not whoop ; and, in the de- 
clining stage, there is much of habit in the paroxysmal 
nature of the cough, so much so that, as is well known, it is 
constantly happening, months after the cessation of the 
cough, it returns again, perhaps more than once, with nearly 
characteristic features, under the stimulus of some perfectly 
neutral catarrh. 

As regards the nature of the whoop there has, at one 
time or another, been much discussion, but it appears to me 
that too much attention has been paid to it. The whoop is 
the natural consequence of the paroxysmal cough, and is 
probably facilitated by the flexibility of the laryngeal carti-. 
lages in young life. The nearest approach to the cough of 
whooping-cough is the sudden paroxysm induced by food 
(usually fluid) getting into the rima glottidis. We have 
there the remarkably sudden onset of a number of rapidly 
succeeding expiratory efforts, till the face becomes turgid, 
the eyeballs almost starting, and the eyes run with tears. 
In some cases a mild whoop is not uncommon, and is clearly 
then the sound produced by the influx of air through parts 
which are not ready to allow it to pass easily. Whether 
they are actually in a state of spasm seems to me to be 
doubtful — all that seems requisite appears to be some want 
of harmony in the laryngeal muscles such as would produce 
at any rate a relative incapacity in the size of the conduit to 
the thoracic cavity, which needs, having been emptied to an 
extraordinary degree, to be filled with more than usual 



26o THE DISEASES OF CHILDREN. 

rapidity. There is also another class of cases which bear 
upon the whoop — viz., such as frequently make an inspira- 
tory crow. There are some babies who, under the stimulus of 
any sudden excitement, such as waking from sleep, or sud- 
denly being carried from a warm room to cold air, have a 
well-marked inspiratory crow, not so noisy as in pertussis, 
but still surely of like nature. I have long held that this 
condition is one incidental to the infant larynx in a certain 
proportion of cases, for it occurs in perfectly healthy chil- 
dren, goes on for many months, and then disappears. I had 
supposed it to be due to an unusual flexibility of the carti- 
lage, by which, under the call of sudden and deep inspiration, 
the membranes covering them were allowed to close in and 
partially to restrict the entrance of air. But Dr. Lees has 
lately shown the state of the parts in such a case after death, 
and though practically the explanation holds good, for the 
mechanism is the same, the actual condition demonstrated 
is an excessively incurved epiglottis by which the ary-epi- 
glottic folds are so approximated as to form a mere chink. 

Spasm may well aid in accentuating the relative incapacity 
of the rima for the demand which is made upon it to admit 
an excessive supply of air in a given time, but I doubt if the 
existence of spasm is a necessity for the production of the 
whoop. From this it follows that the essential of the disease 
is not the whoop, but the rapid series of expiratory coughs, 
or the stimulus by which this discharging force is set going. 

[The expulsion of a quantity of ropy, tenacious mucus at 
the end of the paroxysm of coughing is also an essential 
feature of the paroxysm.] 

As regards other symptoms, I will only allude to the 
statements that have been made concerning ulceration of 
the fraenum linguae, and increase of dulness over the root of 
the lungs and behind the sternum, as indicative of enlarge- 
ment of the bronchial glands. Neither are of any real help, 



WHOOPING-COUGH. 



26l 



the ulceration of the fraenum occurring chiefly in cases where 
the character of the cough leaves no doubt, and the exist- 
ence of abnormal dulness in the regions indicated being, 
according to my experience, and I have made a frequent 
practice of testing the statement, exceedingly rare and equiv- 
ocal. Whooping-cough, if of any ordinary severity, is usually 
accompanied by wasting, and in bad cases the emaciation is 
sometimes excessive. 

The duration of the disease is very variable, six to eight 
weeks is said to be the usual time. Of 126 cases of my 
own, those lasting three weeks number 7; four weeks, 15 ; 
five, 6; six, 13; seven, 12; eight, 16; nine, 8; ten, 13; 
eleven, 4; twelve, 12; and those over twelve weeks up to 
twenty numbered twenty in all. 

The age at which it most often occurs is between two and 
six years, the exact figures in 314 cases being — 



3 months 


and under, . 


9 


6 


years and under, . 


• 27 


6 


a 


23 


7 


a it 


■ 7 


1 year 


li 


30 


8 


a a 


2 


2 years 


a 


60 


9 


a a 


1 
3 


3 " 


a 


60 


10 


a a 


1 


4 " 


a 


54 









5 " 


a 


• 38 




Total, . 


• 3H 



The mortality amounted to t*venty-four males and six- 
teen females, a total of forty of the 314, or about 12 per 
cent. ; but this is really too high, because it includes all 
cases, whether in-patients or out-patients, and of the in- 
patients naturally the larger proportion are severe cases 
with much broncho-pneumonia. If the two classes of cases 
be separated the mortality amongst the in-patients rises to 
40 per cent., that amongst the out-patients falls to 9 per 
cent. The ages of the fatal cases well illustrate the rule 
that the younger the child the greater the risk. Ten were 
under six months old, four others under a year, twelve be- 



262 THE DISEASES OF CHILDREN. 

tween one and two years, seven from two to three, four 
from three to four, two from four to five, one child died at 
nine and a half of a very lingering broncho-pneumonia, 
probably of destructive nature. Thus in thirty-three out of 
forty deaths the children were under three years of age. 

As regards the causes of death, five-and-tw T enty died of 
broncho-pneumonia; in three of the cases convulsions were 
superadded ; six others had convulsions ; the remaining 
nine died under various conditions, of which I may note a 
drowsy state, probably associated with atelectasis and wast- 
ing, which I suspect is not uncommon. Henoch gives an 
accurate account of cases such as this : They occur in young 
children under a year with apncea, cyanosis, occasional evi- 
dence of bronchitis and broncho-pneumonia, contraction of 
the fingers and toes, and occasionally convulsions. He 
mentions also that occasionally in the complexity of symp- 
toms they simulate very closely cases of tubercular menin- 
gitis. While upon the subject of the mortality from whoop- 
ing-cough, I may add that in so far as the estimate drawn 
from the immediate cause of death, the rate falls no doubt 
far short of the reality — for, though it is difficult to prove 
the fact, whooping-cough is a fertile source of caseous dis- 
ease of the bronchial glands and tuberculosis, and of dilated 
bronchial tubes with all th& chronic ills of lungs and heart 
which are associated therewith. 

Modifications. — Pertussis is not a disease which shows 
much variety — it may be very mild so as hardly to be 
recognizable, or it may be very severe. Either stage may 
vary ; the febrile onset being excessive or prolonged and 
obscuring the paroxysmal, or the initial stage maybe hardly 
noticeable and the whoop the first thing to attract attention. 
There may be much pneumonia or none at all ; and as re- 
gards other symptoms, there may be much or little haemop- 
tysis — much or little vomiting — much or little wasting. 



WHOOPING-COUGH. 263 

The haemoptysis and vomiting are in proportion to the vio- 
lence of the cough, and the wasting is in proportion to the 
vomiting. In very severe cases the whoop disappears alto- 
gether, and the cough is associated with an amount of laryn- 
geal obstruction so as to resemble laryngismus. Such cases 
are liable to general convulsions, and are very dangerous. 

Complications. — I shall only mention epistaxis, haemop- 
tysis, ulceration of the fraenum linguae, convulsions, and 
broncho-pneumonia ; pleurisy, pericarditis, and laryngitis. 
Of these, convulsions and broncho-pneumonia alone are of 
importance. Hemorrhage from the nose, mouth, or lungs, 
and a fortiori from the ear — which is mentioned by writers 
as an occasional occurrence — is never so profuse as to cause 
any anxiety; and ulceration of the fraenum linguae is hardly 
worth a note. It occurs occasionally. I have noted its 
presence four times in twenty-two cases. It is an indication 
of a violent cough, and is probably due to the fretting of 
the fraenum against the lower incisor teeth. Epistaxis of 
some severity I have noted as occurring thirteen times in 
the 314 cases, though doubtless, in minor degree, it is present 
far more commonly than that. Haemoptysis is excessively 
common, and convulsions constitute an element of great 
gravity; they are mostly present in young children, or are 
associated with severe broncho-pneumonia. Of nine cases, 
five were children of a few months only — one nine weeks, 
one of twenty months, one of eighteen months, one of five 
months, one of seven months, one a "baby." The other 
three were cases of broncho-pneumonia with convulsions 
supervening, and probably causing death. In some chil- 
dren a profound stupor takes the place of convulsions, and 
if possible is of even graver significance. 

Broncho-pneumonia is met with in every variety as re- 
gards its degree and the position which the disease occu- 
pies in the lungs. As a rule, it is characterized by being 



264 THE DTSEASES OF CHILDREN. 

wide-spread. There may be patches of disease about the 
front of the lungs, along the anterior edges, or round the 
nipple more particularly. The root of the lung is a favorite 
spot for all the pneumonias of children, that of pertussis 
not excepted ; and not very uncommonly the disease may 
be excessive and occupy the greater part of one, or even 
both, bases. Moreover, it sometimes happens that a some- 
what extensive pneumonia rapidly clears up. I have quite 
recently had a child aged two under my care in the hospital. 
There was extensive consolidation at both bases, indicated 
by loud tubular breathing and other signs, and the greater 
part had cleared in five days. On the other hand, broncho- 
pneumonia is also exceedingly likely to become chronic in 
pertussis, and in young children the middle lobe of the 
right lung appears, for some reason or other, to be particu- 
larly prone to slowness of repair. This lobe is very liable 
to pass into a solid condensed state of leaden color, and on 
section to be studded over with crenated patches of caseous 
pneumonia, each with a dilated bronchial tube in the centre 
full of thick pus, or actually softening into cavities. Pleurisy 
is naturally not infrequently associated with whooping- 
cough, mostly by extension from patches of pneumonic 
consolidation; and pericarditis when it occurs (I think but 
seldom) probably originates in a similar manner by direct 
extension. Laryngitis I have noticed as occurring in five 
cases, but in none has it been of any severity. 

Results and Sequelae. — Emaciation may very properly 
be considered as a result of pertussis, for several reasons. 
In itself it is no unimportant condition that a child should 
be little more than a skin covered skeleton. The viscera 
under such circumstances must risk various forms of degen- 
eration, and it might naturally be supposed that so bad 
nutrition would dispose towards cheesy change in the 



WHOOPING-COUGH. 



265 



glands and a secondary tuberculosis ; and that such is 
actually the case many have very little doubt. 

Atelectasis, or collapse of the lung, is another important 
consequence, important in itself, as being in young children 
extensive, and causing death ; important in the further con- 
sequences it entails, of broncho-pneumonia, emphysema, 
and dilatation of the bronchial tubes, all which results come 
about very naturally as the consequences of collapse. The 
whooping-cough is associated with more or less bronchitis, 
and this with more or less secretion in the smaller bronchial 
tubes. The expiratory efforts drive the air from the pulmo- 
nary parenchyma, and, unable to return by reason of the 
plugs in the tubes, the lung becomes collapsed in various 
parts. The collapse leads to inflammatory processes in the 
lung, and the tubes of the part become dilated — very often 
a little pleurisy forms on the surface of these patches, and 
perhaps also some adhesion follows, which tends to increase 
the bronchial dilatation. 

Thus it is that after a bad attack of whooping-cough the 
child often remains delicate, with a small and laterally flat- 
tened chest, the lower ribs being expanded over the ab- 
dominal viscera, and thus causing the disproportion between 
the abdomen and thorax which is so common as a result of 
old atelectasis. 

The relation of cheesy bronchial glands and phthisis to 
pertussis is no doubt a question of much difficulty, for it is 
not only difficult to obtain the direct proof when one dis- 
ease succeeds another at some considerable interval of time, 
but it is also impossible in many cases to free this question 
from others, such as the effect of intercurrent or concurrent 
measles, of hereditary taint, constitutional predisposition, 
etc. Nevertheless, I feel sure, and there are many who 
think likewise, that both on the ground of probability and 
the ground of fact, pertussis is a frequent source of cheesy 



266 THE DISEASES OF CHILDREN. 

glands and tuberculosis. That such occurrences are prob- 
able, is only too evident when we remember the bronchitis, 
the broncho-pneumonia, the swelling of the bronchial glands, 
that characterize so many cases of the disease, and on the 
ground of fact we are all unfortunately too familiar with so 
many cases where cheesy bronchial glands, cheesy pneu- 
monia, and disseminated tubercle in the lungs and viscera 
have succeeded pertussis, to have less than an almost posi- 
tive conviction. And I believe it will be worth while to 
remember that when after pertussis the child remains wasted 
for a long time, and the cough still preserves its paroxysmal 
character even months after the attack, the case should be 
very carefully scrutinized from all points with reference to 
settling the question of the existence of glandular disease. 

[The wasting spoken of may be due to mucous disease, a 
frequent accompaniment and not infrequent sequel of per- 
tussis. The bulk of the mucus ejected at the end of the 
paroxysms of cough comes from the stomach, and the intes- 
tines, as shown by the stools, also secrete large quantities 
of tough stringy mucus.] 

iEtiology and Pathology. — It is a disease which is said 
to be more common in females than in males ; but my own 
figures make this doubtful — 136 out of 282 cases being 
males, or very nearly half. It is said also to be more fre- 
quent in the spring months ; but neither does this appear 
very decidedly in this series, although the statement is prob- 
ably correct : 

Cases, .... 
Deaths, 



Jan. 


Feb. 


Mar. April. 


May. 


June 


29 


30 


29 32 


37 


26 


2 


3 


1 3 





7 


July. 


Aug. 


Sept. Oct. 


Nov. 


Dec. 


22 


10 


6 14 


33 


16 


O 





2 


2 






Cases, . . • . . .22 
Deaths, 

The excess of mortality in the winter months is undoubted. 
It is a disease which occurs in epidemics and which is un- 






WHOOPING-COUGH. 267 

questionably contagious, whilst the contagion is capable of 
-ion from one child to another by articles of clothing 
>ut any actual contact of the diseased with the healthy. 
It is also protective against any recurrence. Thus it has all 
the characteristics of a germ disease, although what may be 
the nature of the virus we, as yet, know not. It is usually 
supposed that the germs, which some have thought they 
have discovered in the shape of micrococci in the respired 
air and in tlie bronchial mucus, act locally upon the mucous 
membrane of the respiratory tract, and thus lead to the pul- 
monary phenomena which have been described. But this 
view fails to account satisfactorily for the neurotic element 
of the disease, and, on the whole, I think it best to say that 
diphtheria is the disease with which it has most analogies. 
Diphtheria is unquestionably a blood disease, yet it tends to 
fasten itself upon the throat, and it is also followed by a 
nerve lesion which must be definitely localized, if we are to 
judge from the uniform character of the paralytic symptoms. 
Whooping-cough behaves in much th manner. In 

the first place, it would seem to be a blood disease, as evi- 
denced by the onset and catarrhal stage of the fever; and, 
in the next place, the virus localizes itself in part in the res- 
piratory centre — and thus brings about a nerve discte 
which ends in the expiratory cough — and in part upon the 
pulmonary surface, leading tc the swelling of the mucous 
membrane, the bronchitis, the pneumonia, and the 
of the bronchial glands. Given these two sets of condit: 
no doubt the one tends to intensify the other; the over-sensi- 
bronchial surface will provoke nerve discharge, and the 
e discharge will tend to increase the peripheral disturb- 
ance. The difficulty in the way of acknowledging the specific 
nature of pertussis — and that there is a difficulty is shown 
the fact that some even yet call it a neurosis, and refuse 
to it any specific nature, while others feel there is something 



268 THE DISEASES OF CHILDREN. 

peculiar in its behavior which makes its presence incongruous 
in any group of diseases — seems to me to be in the impossi- 
bility of fixing what is the limit of the vitality of the conta- 
gion. In most of the specific fevers we have been able to fix 
some limit from the behavior of the disease; but to pertussis 
there is none. It lasts mostly six weeks to two months, but 
the whoop may continue long after that. All that can be 
said of it in this respect is that it is most contagious in the 
early stages, but the virus appears to want any definiteness 
of course. 

One cannot argue against the specific nature of the disease 
from the absence of fever, and the tendency to recurrence of 
a non-contagious cough ; diphtheria is sometimes so mild 
as to have but little fever, and its nerve lesion is quite distinct 
from contagion. The cough is started by the disease, but 
soon tends to become a habit, and thus to return again and 
again, until the habit dies out in the oblivion engendered by 
more healthy and regulated discharges of nervous energy. 
And it will be quite impossible to arrive at any conclusion 
upon the natural history of pertussis germs until we leave the 
whoop out of our calculations altogether, and pay more at- 
tention to the catarrhal stage. 

Morbid Anatomy. — The actual lesions found in whoop- 
ing-cough are not many. Of chief importance, at any rate 
as a cause of death, is broncho-pneumonia. This shows 
itself in children by more or less wedge-shaped patches of 
solid, perhaps tough, leaden-colored material, in which the 
vessels and tubes stand out prominently, and the latter are 
often dilated. If the diseased area is large, there will be 
seen, in addition, ill-defined areas of redder or paler color, 
dotting it over, perhaps, with a rather sandy or granular 
appearance. It is common to find the greater part of one 
or both lower lobes affected in this way, or the parts about 
the roots of the lungs, and spreading outwards in the middle 



WHOOPING-COUGH. 



269 



zone quite to the surface. The parts of the lungs corre- 
sponding to the mammary region are particularly liable to 
be affected, and thus to lead the unwary to conclude that he 
is dealing with a secondary phthisis. The bronchial tubes 
contain a thick glairy muco-pus, and the mucous membrane 
of the trachea and larynx are often injected or even minutely 
ecchymosed. The margins of the lungs are usually cedema- 
tous. As regards the bronchial glands, there can be no 
doubt that they are liable to acute swelling ; but the number 
of children dying of a perfectly uncomplicated pertussis is 
not large, and in many cases the swelling that is found is the 
natural result of broncho-pneumonia. 

Various cerebral conditions have been described, such as 
congestion, oedema, serous effusion, and the like ; but they 
are all of very doubtful significance ; ecchymosis, or, in some 
cases, larger extravasations of blood, such as to have de- 
served the name of meningeal apoplexy, can alone be said 
with certainty to have been due to this disease. 

In chronic cases other lesions are found ; the broncho- 
pneumonia undergoes 'degenerative changes which convert 
it either into solid cheesy masses or isolated nodules with 
softening centres. The bronchial tubes become more di- 
lated, and, in many cases, a disseminated tuberculosis of the 
lungs takes place. The bronchial glands also are liable to 
lose their red, swollen, fleshy appearance, and to become 
converted into masses of firmer yellow cheesy substance like 
those in the lung. The explanation of these further changes 
is not hard to discover. The catarrhal pneumonia is well 
known to present under many circumstances a tendency to 
such changes, and the chronic disturbance of the respiratory 
tract, which we recognize as chronic bronchitis, is only too 
likely to perpetuate the initial hyperplasia of the bronchial 
glands and to lead to their caseation and to the development 

23 



27O THE DISEASES OF CHILDREN. 

of acute tuberculosis of the lungs and viscera, or to an acute 
tubercular meningitis. 

Diagnosis. — There can be very little difficulty as regards 
the whooping stage ; but it may be as well to insist specifi- 
cally, although it, to a certain extent, follows from the re- 
marks already made upon the nature of the whoop, that the 
peculiar cough may return again and again upon trivial ex- 
citement. Further than this, it is allowed by all writers that 
chronic diseases of the bronchial glands sometimes produce 
a noisy paroxysmal cough very like pertussis. The distinc- 
tion will be in the absence of any definite stages ; the absence 
of any evidence of infection — such cases occurring sporadi- 
cally and not in epidemics; the absence of whoop; the evi- 
dence of associated lung disease ; possibly symptoms of 
spasmodic asthma; and a history of wasting long before the 
occurrence of the cough. 

[In enlarged bronchial glands there is dulness over the 
first bone of the sternum, stridor on inspiration and weakened 
respiratory sound over the lung provided a bronchus be 
pressed upon, and if the return of blood in a large vein is 
interfered with, besides lividity of the part and turgescence 
of the vein, there will be a hum heard through the stetho- 
scope placed over the seat of pressure. Before the swelling 
has become so large as to produce the symptoms just men- 
tioned, Eustace Smith's method of examination gives most 
assistance in making the diagnosis. He writes: "If the 
child be made to bend back the head, so that his face be- 
comes almost horizontal, and the eyes look straight upwards 
at the ceiling above him, a venous hum, varying in intensity 
according to the size and position of the diseased glands, is 
heard with the stethoscope placed upon the upper bone of 
the sternum. As the chin is now slowly depressed, the hum 
becomes less loudly audible and ceases shortly before the 
head reaches its ordinary position."] 



WHOOPING-COUGFI. 2J I 

In the catarrhal stage, however, there may be considera- 
ble difficulty. Indeed, in many cases, we can only have our 
suspicions and act accordingly, watching in individual cases 
for a confirmation of the diagnosis in the onset of the par- 
oxysmal cough. Here, as in so many other conditions, to 
be forewarned and on the look-out is the true preparation 
against mistake; not a definite memoria technica of phe- 
nomena, any one of which, or all, may fail us when doubts 
arise and we come to test them. 

[If, however, an epidemic be prevailing, if the cough be 
paroxysmal and worse at night, if the eyelids are puffy and 
marbled with injected vessels, and the conjunctiva suffused, 
the onset of whooping-cough may be strongly suspected.] 

Prognosis. — In very young children (under a year old) 
the disease is always a cause of anxiety ; but in uncompli- 
cated whooping-cough at four or five years of age the mor- 
tality is not large. The gravity of the case will depend upon 
the complications that may arise. If there should be much 
broncho-pneumonia, naturally the danger will be great; so 
also if convulsions are severe. Then, again, if the child is 
rachitic and its chest depressed, the occurrence of whooping- 
cough will tend to increase the already existing collapse and 
bronchitis and to set up pneumonia, and the risk increases 
in proportion. 

The frequency with which complications occur must vary 
no doubt in the practice of individuals ; but it may be as 
well to state that Meigs and Pepper give, as the result of 
their practice, 65 cases associated with complications out of 
208, or nearly one-third. Of 320 cases of my own, 57 had 
broncho-pneumonia or bad bronchitis; 16 others, various 
other complications. Probably, therefore, from a fourth to 
a third of the cases may be expected to be complicated in 
some way, varying somewhat with the epidemic influence 
and the time of year at which the cough occurs. Atmos- 



272 THE DISEASES OF CHILDREN. 

pheric changes have a most important bearing upon pertus- 
sis. It has been repeatedly noticed in the whooping-cough 
ward at the Evelina Hospital that the children are worse, 
even when otherwise doing well, when the wind turns cold 
or suddenly changes ; and it is notorious that the disease 
runs a much less determined and persistent course in sum- 
mer than in the colder seasons of the year. 

Lastly, I would say again, beware of too hastily assuming 
the existence of phthisis where the broncho-pneumonia runs 
a chronic course ; for it is noteworthy that not a few cases 
with pronounced signs of chronic consolidation of various 
parts of the lungs and extreme emaciation, ultimately — and 
sometimes rapidly — mend and become completely restored 
to health. 

Treatment. — This is a very important part of the subject 
if it be true, as is said, that this is the most fatal of all dis- 
eases of children under one year. Some people think and 
teach that whooping-cough will run its course and gradually 
wear itself out, and that no drugs influence it materially. 
Some deny to it any specific virus, and consider it merely a 
nervous trick associated with catarrh, and, just as some tricks 
are easily caught in childhood, so, they say, is the whoop 
of whooping-cough. It is no doubt a disease in which, until 
trial has been made, it is difficult to say what drug will act 
best in any particular case. But that there are drugs which 
are of decided use I have no doubt whatever; and there 
are moreover other points in the treatment which it will be 
well to make oneself acquainted with. In the first place 
let it be again repeated that whooping-cough is generally a 
disease of two stages ; there is the primary catarrhal stage 
— in which the child is feverish and ill ; and there is the 
after or whooping stage — in which the child may not be ill 
at all, though this of course will necessarily depend upon 
the severity of the disease. 



WHOOPING-COUGH. 273 

In the catarrhal stage there are few remedies of more 
value than simple expectorants. I give the mist, oxymellis 
co. of the Guy's Pharmacopoeia, which consists of vin. ipecac, 
tr. camph. co., nitrate of potassium, and oxymel. Sometimes, 
if the child is four or five years old, tr. camph. co. alone is 
sufficient, the benzoic acid and opium of which make it a 
good sedative expectorant. Often a little dilute nitric acid 
proves useful. Some have suggested this as a specific for 
whooping-cough; and though it is impossible to indorse 
this view, some children seem to be relieved by its use, and 
with syrup, and perhaps a little Tolu, it does not make a bad 
mixture for a child to take. This is all that we can do for 
the first ten days or so, so far as the experience of the pres- 
ent guides us. At the same time I would say if whooping- 
cough is a disease dependent upon a specific virus or germ, 
it is as well to be alive to the fact, and to make trial of any 
new remedies that may be suggested. There is no reason 
that I know of why we may not some day find a specific for 
pertussis, as quinine is for ague, and we should certainly try 
any remedy that may be suggested as likely to prove useful. 
With this in view I have tried salicylic acid, thinking it 
might possibly have an antiseptic influence — possibly a ner- 
vous influence over the disease — but without any success. 
I have tried carbolic acid both internally and as an inhala- 
tion, equally without success, and expectorants are upon the 
whole the most useful drugs. For the whooping stage also 
many remedies have been suggested, and I think I have 
tried almost everything that has been suggested. There 
can be no doubt that all drugs fail to cut the disease short 
in most cases, but some are of considerable value in con- 
trolling it. Far before all others I must, as most others have 
done, place belladonna. This drug has been recommended 
very strongly by Trousseau, and it is one of which many 
think highly, though some think it of no value. I cannot 






2/4 THE DISEASES OF CHILDREN. 

doubt that it is often very effective; but chiefly so when it 
is given in large doses. Trousseau advises the use of the 
extract of belladonna given in the morning as a single dose, 
beginning with one-third of a grain and gradually increas- 
ing it. I confess, however, to having a liking for the tincture 
or the liq. atropine. * These are more manipulable, whilst 
the dose of either can be readily increased, and it is essential 
to the treatment that considerable doses should be adminis- 
tered if the remedy is to do good. Many advise that the 
drug should be pushed until it produces some known physi- 
ological effect. I doubt if this be necessary. Children are 
very tolerant of belladonna, and the cough is generally con- 
trolled some time short of any poisonous effects. At any 
rate, my own experience undoubtedly corroborates that of 
most other observers as to the good effects of the drug, 
although I cannot recall to mind more than one or two in- 
stances, and those of children in hospital, where any physi- 
ological effect (dilatation of the pupil) has been produced. 
As regards the actual dose, ten or twelve drops of the tinct- 
ure may be given to a child three years old to commence 
with, and the quantity increased up to twenty drops or more 
it necessary, and this every three or four hours. Even in 
very young children large doses may be given with advan- 
tage ; I have given ten drops three times daily to a child of 
five months old, and no dilatation of the pupils resulted. 
This child began at fourteen weeks with four minims, the 
dose was then increased to six, afterwards to eight, and then 
to ten drops ; and infants of five and six weeks old will take 

* Liquor Atropine, Br. P., contains : 

Atropia, ........ 4 grains. 

Rectified Spirit, ...... I fluid drachm. 

Distilled Water, ...... 7 fluid drachms. 

Dissolve the atropia in the spirit, and add this gradually to the water, 
shaking them together. — Ed. 



WHOOPING-COUGH. 275 

four or five minims easily, and with relief to the violence of 
the cough.* 

But as regards the tolerance of the drug which children 
exhibit, let me say this much, that although it is undoubted, 
I believe it always wise to feel one's way, and to watch the 
effects carefully. I am no advocate for giving a thumping 
dose offhand. It is best to begin with some dose propor- 
tionate to the age, three or four drops in babies, and five, 
six, eight, or even ten for older children, and watch its 
effect. Should it control the cough — well, what need to 
increase the strength ? If not, let the dose be increased drop 
by drop till it does so or fails, when something else must be 
tried. Some prefer to give the drug in small doses at more 
frequent intervals, and there is much to be said in favor of 
this plan on the score of scientific therapeutics. But, except 
in hospitals with trained nurses, it is difficult so to work it 
as to run no risk, unless the child's attendants be exception- 
ally furnished with medical intelligence. But, however we 
give it, it will undoubtedly relieve many cases, and appear 
to stop some. 

[Belladonna by inhalation has been employed with very 
satisfactory results, reducing the frequency of the paroxysms 
of coughing and overcoming the whoop after from four to 
eight inhalations. Enough should be inhaled to produce 
the physiological effects.] 

There are many other drugs which are useful. Quinine 
certainly does some cases good, but it requires, like bella- 
donna, to be given in somewhat large doses. I have given 
as much as two and three grains to a child three times a 
day. Some time ago I tried benzol in this stage, and cer- 
tainly with good results. For some months all, or nearly 

* The difference in the strengths of the British and American preparations 
of belladonna must be remembered. The latter are about twice as strong. — 
Ed. 



276 THE DISEASES OF CHILDREN. 

all, uncomplicated cases of pertussis were given five to ten 
drops of benzol in syrup and pure water, and in a good 
many cases they had previously taken other remedies with- 
out avail. The cough in many became less frequent and 
less violent. The objections to it are that it is very diffi- 
cult to make palatable, and it occasionally causes sickness. 
Carbolic acid has been recommended, and I have tried that 
also, both as an inhalation and internally. The inhalation 
is troublesome, and seems to me of very doubtful use ; 
and this holds good, whether applied locally to the indi- 
vidual or generally to the atmosphere in which he lives. 
Nor have I been by any means impressed with its value as 
an internal remedy (F. 39). Sometimes I have given as much 
as a grain three or four times a day. 

Alkalies are also very useful. The carbonate of potas- 
sium, in doses of a few grains every few hours, is strongly 
recommended by Meigs and Pepper as useful in their hands 
and those of others ; and I am convinced that the combina- 
tion of bicarbonate of sodium and belladonna, a mixture 
that has long been in vogue at the Evelina Hospital, is a 
very valuable combination. 

Alum is a remedy which may perhpas be mentioned next, 
because, though it is in some cases singularly useful, its 
action is probably the opposite of the alkaline carbonates. 
They possibly aid by facilitating expectoration — the use of 
alum, on the contrary, is said to be indicated, when there is 
already an excessive secretion from the bronchial tubes ; 
but having tried it with this special object, I feel free to 
confess a considerable doubt as to having ever accomplished 
the end aimed at, though as to the occasional control exer- 
cised by the drug over the disease I have no doubt what- 
ever. 

[I have found the following combination of alum and 
belladonna very useful : 



WHOOPING-COUGH. 277 

R. Pulv Aluminis, : gr. xxiv. 

Ext. Belladonnoe, gr. }£. 

Syrupi Zingiberis, 

Aquoe, aa f gjss. M. 

S. — One teaspoonful every two hours, for a child of one year.] 

Then, again, the bromide of ammonium or of potassium 
and chloral are highly useful in some cases. The succus 
hyoscyami, and all and more than these, are useful in their 
turn, and, indeed, there is much about the treatment of per- 
tussis which brings out clearly the neurotic element, for, 
like epilepsy, it would seem that there are many drugs 
which avail for a time, but in the long run, and when sur- 
veyed rigidly, one seems to have as much or as little influ- 
ence as another. I am more particularly impelled to say 
this, because in practice amongst the out-patients, I was 
decidedly of opinion that benzol gave better results than any 
other remedy in pertussis ; but when we came to test the 
results upon the in-patients with a rigid appeal to facts, the 
results were much more equivocal. 

But there are other important points in treatment which 
are not less worthy of notice. Whooping-cough is a dis- 
ease which, in most cases, is attended with frequent vomit- 
ing. The paroxysms of coughing will come on twelve, 
fifteen, twenty times in the course of the day, and each time 
very likely will end with vomiting. It is therefore easy to 
understand that nutrition is in some cases much interfered 
with, and the child becomes much emaciated — it is, in fact, 
starved. In these cases the most watchful cafe is required, 
and the routine must be entirely subservient to this exigency 
of vomiting ; the food should be entirely fluid and highly 
nutritious ; in some cases it may with advantage be artifi- 
cially digested, and it must be given very often, a little at a 
time. Moreover, food should always be administered di- 
rectly after an attack, so that as long a time as possible may 

24 



278 THE DISEASES OF CHILDREN. 

be obtained for absorption before the contents of the stom- 
ach are again rejected. By this means a good deal may be 
done to combat excessive wasting, and in averting this we 
no doubt do the best that can be done to ward off those 
degenerative changes of which mention has already been • 
made. 

Of other remedies, let me first mention an occasional 
emetic as very useful in the earlier days of the whooping 
period. It clears the bronchial tubes of their contained 
mucus, allows the lungs free play, and in this way by acting 
at the periphery does what can be done to quiet the central 
instability. 

In the later stages, friction to the spine is an old remedy 
that I believe to be useful ; and in the chronic whooping 
stage, few things act so satisfactorily as change of air. 

I have previously insisted that the remedies which are 
used for the second stage are not suitable to the first, but in 
saying this let me repeat that one expressly reserves the 
question of specifics. The remedies now in vogue for the 
second stage are in no sense specifics ; they control the 
violence of the paroxysm, but have no destructive action 
upon the supposed germ which causes them. But if the 
disease be due to a germ, and the behavior of the disease is 
certainly in favor of this view, then it may be hoped, as I 
have already said, that a specific will one day be found, and 
obviously any drug exhibited with such an object must be 
applicable at any time during the life of the germ. 



TYPHOID FEVER. 



279 



CHAPTER XVII. 



TYPHOID FEVER. 



Typhoid Fever. — No period of life is exempt from enteric 
fever, and cases sometimes occur in infants of but a few 
months old ; but of thirty-eight cases from my notes, two 
were under a year old (both being fatal, and the diagnosis 
verified by an inspection), one under two, two of three and 
under, two of four, four of five, five of six, six of seven, 
three of eight, five of nine, six of ten, and two of eleven 
years, so that thirty-one of the thirty-eight were over four 
years of age. 

Symptoms. — As in adults so in children — fever, rose 
spots, diarrhoea, enlargement of the spleen, and bronchitis. 
Nor are children by any means exempt from the tendency 
seen in adult life to a repetition or relapse of all the symp- 
toms, when the primary fever has completely, or all but, run 
its course. But the disease is generally milder in children 
than in young adults ; and its more markedly remittent type 
is notorious. The fever is, generally speaking, of insidious 
onset. Headache and loss of appetite are first noticed, ac- 
companied, perhaps, by occasional vomiting. It is charac- 
terized often by very few symptoms during the day — except 
fretfulness — though symptoms of fever, with weak pulse and 
dry skin, are not wanting to careful observation. Towards 
evening the face becomes flushed, or a red burning spot 
surmounts one cheek, the lips become red, and the tongue 
dry; the child's sleep is restless and disturbed by delirium; 
towards morning the fever subsides, and hopes are enter- 
tained of speedy recovery. Day after day the same history 



280 THE DISEASES OF CHILDREN. 

repeats itself, and now the abdomen is tumid, the spleen is 
large ; there is diarrhoea, and perhaps rose spots appear ; 
there is considerable cough, and the child rapidly becomes 
emaciated. Sometimes during the afternoon profuse sweat- 
ing may set in, though without relief to the symptoms. 
From these remissions the term u infantile remittent" takes 
its rise ; they are sometimes very marked and appear to 
continue throughout the fever, gradually lessening in severity 
as it runs its course. But this complete picture often fails. 
The duration of the fever is more variable, diarrhoea may 
be absent, and the roseola also. Even the splenic enlarge- 
ment may be wanting, so that the disease is perhaps only 
established by the temperature chart, with, it may be, the 
existence of an associated bronchitis. A large number of 
cases occur with no distinctive feature of any kind. It is 
noticed that a child is ill, and its temperature is found to be 
high — 101° to 103 ; a more rigorous observation is then 
instituted, and it is kept in bed. Then it is found that there 
is continuous fever with evening exacerbations for some 
days, accompanied by tumidity of the. abdomen, and a 
coated or beefy condition of the tongue. At the end often 
or twelve days there are more marked remissions, or else 
by some sudden fall the fever ends, and convalescence is 
established. 

In default of any definite symptoms, there is a disposition 
to consider cases such as these as being cases of mild ty- 
phoid. Some German authorities, however — Lebert for in- 
stance — adopt the term infective gastritis for febrile attacks 
of this kind ; supposing, in unison with doctrines now in 
vogue, that the products of gastric catarrh are capable of 
infecting the system generally, and thus of keeping up a 
continued fever. The " gastric fever " of English authors 
might usefully be made to convey a like suggestion ; but 
that in common parlance it has come to be synonymous 



TYPHOID FEVER. 



281 



with typhoid fever. I do not wish to assert dogmatically 
that an infective gastritis distinct from typhoid fever has an 
existence, but I allude to the possibility of such a thing for 
the purpose of impressing upon the student that in dealing 
— as he will often be called upon to do — with continued 
fever in childhood, of indefinite type; whilst treating it, as 
he is bound to do, with all circumspection, on the chance 
of the existence of enteric ulceration — he is yet ever to 
bear in mind that other possible causes than the assumed 
one have a claim to consideration, and that careful observa- 
tion and record of all such indefinite types are necessary, 
in the hope that at some future time some order may be in- 
troduced into the at present chaotic domain of " simple con- 
tinued fever." 

Temperature. — In adults the pyrexia of typhoid fever is 
characterized by a gradual rise in three or four days to the 
acme of the fever. Next, by a period of continuous fever 
(103 to 104 ), the morning temperature being a degree or 
so lower than that of the evening ; and at the end of the 
second, or early in the third week, the period of remissions 
sets in, the morning temperature falling to near the normal 
line, the evening rise still continuing for some days. In 
children the same three stages may be noticed, but they are 
seldom so continuous or so well marked. The remittent 
nature of the affection is the most prominent feature of in- 
fantile typhoid, and may characterize more or less the whole 
course of the disease. Further, the remissions need present 
no regularity from day to day in time of their occurrence. 
If the temperature be only noted morning and evening, no 
doubt in the latter it is often high, in the former low ; but 
taken every two or three hours, the chart will be remarkable 
for its irregularity, sometimes running up and down several 
times in the course of twenty-four hours ; and the highest 
point reached may be at any hour, often about 6 p.m., but 



282 THE DISEASES OF CHILDREN. 

sometimes 9 p.m., 6 a.m., 12 p.m., midnight, 3 A.M., or, indeed, 
any hour. All authors appear to have noticed a tendency 
to the occurrence of two distinct exacerbations about 4 and 
9 p.m., with intervening remission and occasional profuse 
sweating. I also have seen the same thing; the type being 
malarial or like the hectic of suppuration. The oscillations 
in these cases are extreme, and if long continued are indi- 
cative probably of severity of ulceration. The difference 
between the lowest and highest temperature for the twenty- 
four hours should not exceed two or, at most, three degrees. 

Nervous System. — In severe cases there may be a good 
deal of noisy delirium occasionally showing itself by a fre- 
quent harsh cry, not unlike that of tubercular meningitis, 
and very perplexing for diagnosis ; in cases of moderate 
severity the child lies stupefied and apathetic, with more or 
less mild delirium at night. Deafness is not uncommon. 

Rose spots have been present in the majority of cases that 
have been under observation at the proper time. To de- 
termine their presence it is necessary to examine the entire 
trunk day by day. But many children among the poorer 
classes are only brought to the hospital at the last stage of 
the disease for continued ailing or emaciation, which is 
thought by the parents to indicate consumption. In many 
of such the rose spots are absent. They are absent through- 
out in perhaps a fourth of all the cases. In a considerable 
proportion they are but few in number, and may easily be 
overlooked. As in adults, they appear in crops from the 
eighth to the twelfth day onwards. Sudamina are often seen 
late in the second or third week. 

Bronchitis may be a prominent symptom, and not infre- 
quently is associated with slight haemoptysis ; sometimes it 
is very severe, and it may prove fatal. I have seen it so 
severe as to mask the nature of the disease altogether, the 
case assuming the aspect of acute bronchitis. 



TYPHOID FEVER. 283 

Splenic enlargement is present in many cases, and should 
always be looked for as an aid to diagnosis. Henoch states 
that he found it palpable in thirty out of seventy-five cases ; 
in others it could be distinguished only by percussion. The 
enlargement is present sometimes in the primary fever, 
sometimes in the relapse ; and, I should have said, was in 
all probability related to the intensity of the fever; but too 
little is known about the symptom to speak with certainty. 

The tongue is often characteristic. It may be coated 
with a white creamy fur on the dorsum, with red edge and 
tip, or it may be of a beefy red all over, with prominent 
papillae or unnaturally smooth. 

Duration is much more variable in children than in 
adults ; many cases last only ten or twelve days ; seventeen 
to nineteen days is not by any means an uncommon dura- 
tion. Then, again, many cases give a preliminary history 
of three or four weeks of malaise before the onset of any 
definite symptoms. It is probable, however, that could these 
be more carefully watched, they would resolve into cases in 
which a mild primary fever, unrecognized, had led on to a 
relapse. For instance, a girl, aged seven and a half, had 
been ill three weeks, had been much worse for seven days, 
and had suffered from diarrhoea for three days. She was 
admitted with a steady fever of 104 , diarrhoea, rose spots, 
and enlargement of the spleen, and the complaint ran a course 
of fifteen days. The total period was thus divisible into two 
of fourteen days each. Again, a boy, aged five, said to have 
been ill three weeks, but worse with diarrhoea three days, was 
admitted with a temperature of 104 , and the complaint ran 
a course of nineteen days ; a total, again, well divisible into 
two attacks of between two and three weeks each. Many 
such cases could be given. 

Morbid Anatomy. — The ulceration of Peyer's patches and 
of the solitary glands is less frequent, less extensive, and less 



2 34 THE DISEASES OF CHILDREN. 

characteristic than in adults, and the younger the child the 
more is this true. In not a few cases no ulceration of any 
kind has been present ; in others, one or two small ulcers in 
parts of the agminated glands ; in others, slight raised fleshy 
swellings of the entire patch or of parts of it. As in adults, 
the large intestine may be affected — nay, may even be the 
chief seat of ulceration ; and I have once seen death from 
the after-result of hemorrhage from typhoid ulceration of 
the colon. Perhaps it is in consequence of the mildness or 
the ulceration that the fever is so variable — that the late of 
oscillating temperature may sometimes fail — that tympanitis 
and hemorrhage from the bowels are uncommon — and that 
death by perforation is one of the rarest modes of termina- 
tion. Otitis maybe present, and, in rare cases, parotitis ; 
one of my own cases proved fatal in this way. I have only 
once seen death from acute peritonitis. It was associated 
with jaundice, ascites, and plueritic effusion in a child of 
four and a half years. For the most part, the morbid anatomy 
of typhoid in children differs from that of adults by wanting 
all the more characteristic features. Slight ulceration of the 
solitary glands and of Peyer's patches, or swelling only, 
combined with a swollen spleen, and more or less sodden 
solidification of the bases of the lungs, complete the picture 
in most cases. 

The following case may be given as an illustration of these 
points. It is an exceptional one for two reasons: the early 
age of the child and the fatal result: 

A male child, four years old, attended as an out-patient 
at the Evelina Hospital with diarrhoea, a tense abdomen, 
and some rose spots on its buttocks. It was only seen once. 
It died in convulsions. I made an inspection three days 
after death. 

The spleen was large and rather soft. 

The mesenteric glands were large and ecchymosed. 



TYPHOID FEVER. 285 

Throughout the small intestines Peyer's patches were in- 
jected and swollen, so as to be slightly raised above the 
surrounding level in a flat plaque. The upper patches were 
mostly ulcerated ;' one lower d©wn had a circumferential 
line of ulceration as from a slough just commencing to sepa- 
rate, and others of them had small ulcerated pits in them. 
The ileo-caecal valve was ulcerated. 

There can be little doubt that this was a case of typhoid 
fever. There was the large, soft spleen, the swollen and 
ecchymosed glands, and the swollen and ulcerating Peyer's 
patches ; but the swelling of these was very slight as com- 
pared with that usually seen in adults. 

Diagnosis. — It is a matter of frequent occurrence that a 
pale, wasted child is brought to the out-patient room with a 
history of four or five weeks' illness, with diarrhoea and 
cough, the expectoration being slightly streaked with blood. 
These are signs from which the student not unnaturally con- 
cludes that the disease is of phthisical nature. Moreover, 
this opinion may be apparently confirmed when the chest is 
examined and he finds bronchitic rales present; or some 
roughened respiration at the apices which he considers to 
be bronchial, and therefore to indicate consolidation. A 
further examination, however, shows that there is no dulness 
on percussion, and but slight, if any, difference between the 
abnormal sounds on the two sides ; and, perhaps, the tongue 
is red and glazed, and the abdomen full. After a day or 
two in bed the case turns out to be typhoid fever in the 
second or third week. So often does this picture present 
itself in practice, that I believe it to be of importance to 
insist that w r hen in children prima facie phthisis is indi- 
cated, the student should have typhoid fever as an asso- 
ciated idea and proceed to decide between the two. Typhoid 
fever is one of the wasting diseases of childhood. 

Sometimes it is quite impossible to decide between acute 



286 THE DISEASES OF CHILDREN. 

tuberculosis and typhoid fever; the insidious onset is the 
same for both, and the temperature chart of both is one 
of oscillations, owing to the evening exacerbation of the 
fever. Vomiting is sometimes a feature of early typhoid 
fever, and a slow pulse not by any means infrequent. On 
the other hand, I have several times, noticed diarrhoea in 
acute tuberculosis, and a tuberculous spleen may often be 
felt below the ribs ; thus it may happen that a positive opin- 
ion can only be arrived at after careful observation, at more 
than one visit, of all the circumstances of the case, and that 
in some cases — perhaps not very common, but yet suffi- 
ciently frequent to necessitate insistance on the fact — the 
two diseases cannot be distinguished. 

[Meningitis is sometimes extremely difficult to distinguish 
from typhoid fever. I will illustrate this by three cases : 

A boy, aged twelve, came home from school ailing, after 
the mumps. A boy at the school had had typhoid fever there 
some months previously, but he was thought to have taken 
it from elsewhere, the drainage and sanitary conditions being 
perfect. The lad was pale and thin, with a rather beefy 
tongue, a full and tense abdomen, and a large spleen ; his 
evacuations loose, but not frequent ; no spots ; temperature, 
ioi°. For twenty-four days he thus continued, perfectly 
clear in his intellect, but with slight intolerance of light, a 
frequent short cough, a high but oscillating temperature, 
and gradually increasing muscular tremor. He also had 
rather frequent priapism, the import of which did not strike 
me till afterwards. Gradually a dry pleuritic rub developed, 
and some evidence of partial consolidation, in diminished 
resonance and blowing respiration in the scapular region. 
Next there came pain on movement, delirium at night, and 
then almost suddenly he passed into a comatose condition, 
with rigidity of his extremities and more priapism, and he 
died after an illness of thirty days. For more than three- 



TYPHOID FEVER. 



287 



fourths of that time I was quite unable to decide between 
typhoid fever and general tuberculosis ; but his mode of death, 
combined with various slight symptoms which could be read 
more distinctly after — viz., the intolerance of light, the pria- 
pism, the muscular tremors, and the pains in his extremities 
on movement — made the diagnosis without doubt to be 
cerebro-spinal meningitis." 

Another case, a boy, aged five, was admitted with a 
history of three weeks' illness, chiefly of frontal headache, 
vomiting, and latterly diarrhoea. His temperature was very 
high (io3°-i04°), the condition of one lung was -question- 
able, and he had much delirium. For seventeen days he 
continued in the same condition, without any definite signs 
of typhoid fever, and with many of severe cerebral disturb- 
ance and fever. He had, however, an occasional typhoid- 
looking stool, and the temperature ran high for tubercular 
meningitis ; therefore, on the whole, I favored the diagnosis 
of fever, and so it proved to be. From the seventeenth to 
the twenty-fourth day the temperature fell, and the child got 
well. 

The third case is that of a girl, aged twelve. She had 
been subject to sick-headaches for a long time, but worse 
since a blow on the head a year before. She had also wasted. 
For five days the headache (frontal) had been very bad, with 
frequent vomiting and constipation. She was quite clear in 
her mind, with temp. ioo°, pulse 72, exceedingly irregular, 
but with no intolerance ; the fundus of the eye being normal. 
The disease ran on without declaring itself till pain in the 
neck developed, then squint, and then coma. 

Ulcerative endocarditis will sometimes closely simulate 
typhoid fever, and is all the more difficult to distinguish, in 
that the physical signs of valvular lesion are apt to become 
masked by the formation of fungating vegetations about the 
diseased apertures. Any previous history of rheumatism, 



288 THE DISEASES OF CHILDREN. 

any evidence of valvular disease, and particularly any evi- 
dence that infective maladies of any kind are prevalent, 
should suggest a careful consideration of this possibility be- 
fore coming to any definite opinion. 

Ostitic pyaemia may simulate typhoid fever, and a case of 
this kind has recently been in the Evelina Hospital. A 
child of about eight was admitted, with diarrhoea, much 
abdominal distension, and the general aspect of severe 
typhoid. The result showed a very acute pyaemia, with 
abscesses in parts of the lung. 

Of the incubation and other points concerning typhoid 
fever in general, it is hardly within the scope of the present 
work to treat; but it may be remarked that, as regards the 
incubation — which is said to vary from two days to three 
weeks, and to be most commonly about two weeks — children 
afford virgin soil, undergo changes of body-heat readily, and 
therefore may be expected to mature a poison rapidly ; an 
important consideration when tracing the source of infection. 
Further, it would seem that children are peculiarly sensitive 
to drain emanations, whilst water and milk, which constitute 
so large a share of their diet, have been shown to be the 
more common sources of the introduction of the poison. 

Treatment. — In the majority of cases the treatment is 
simple. The child must be kept in bed, its temperature 
carefully watched, and the diet regulated. The food must 
be fluid, or pultaceous — such as soaked biscuit, custard, 
milk, and beef-tea. Should the stomach be inclined to 'reject 
these, even lighter materials must be given — milk and lime- 
water, or milk and water, whey and artificially digested 
milk, or blanc-mange. As regards drugs, a little dilute nitric 
acid, with syrup, is agreeable and refreshing, and some attach 
importance to its therapeutic value. Quinine is another 
remedy much in vogue with some. In cases of moderate 
duration, no stimulants are necessary ; but when the fever 



TYPHOID FEVER. 



2c°9 



extends to or beyond the third week, and the symptoms 
have been severe, two, three, or four ounces of wine, or one 
or two of brandy, in the twenty-four hours, are often needed 
after the second week. Constipation is not uncommon, and, 
if associated with any distension of the abdomen, is to be 
treated by simple enemata, or a small dose of castor-oil. 
The evacuations should in all cases be treated with some 
disinfectant, and all soiled linen is to be removed at once 
and treated in like manner. As regards the more severe 
cases, the noisy delirium may perhaps indicate the need of 
stimulants; but the relief afforded is not so decided as in 
adults, and, as a rule, I do nothing, provided the child is 
taking its nourishment well. Small doses of Dover's powder 
or bromide of potassium are sometimes beneficial, and a 
tepid or warm bath sometimes exercises a calmative and 
soporific effect. If the temperature is persistently over 103 , 
frequent resort to tepid sponging, cold sponging, an ice pack, 
or the tepid or even cold bath is indicated. An ice-cap to 
the head is occasionally useful in the same way. Quinine 
may be given in one, two, or three grain doses three times 
a day, and I have also tried salicin, but without much evi- 
dent effect. For abdominal distension there is nothing so 
good as turpentine or terebene. Either of these may be 
mixed with mucilage of tragacanth, syrup, and cinnamon- 
water ; or mixed with butter and put at the back of the 
tongue. In this way, five drops of the oil of turpentine or 
two or three of terebene may often be taken without excit- 
ing much resistance. Hillier recommends an enema of as- 
safcetida. 

For diarrhoea, five drops of tincture of opium with an ounce 
of starch-water by enema, is the plan of treatment which 
seems most generally successful ; but two or three grains of 
Dover's powder, given internally once or twice in the twenty- 
four hours, will often be equally efficacious. A moderate 



29O THE DISEASES OF CHILDREN. 

diarrhoea, two or three evacuations in the twenty-four hours, 
is not to be checked. Severe diarrhoea is generally associ- 
ated with abdominal distension, and indicates severe ulcera- 
tion ; and although it is the general practice to give o*piates, 
I prefer to combine them with such other drugs as may have 
an antiseptic effect upon the surfaces of the ulcers, such as 
turpentine, borax, etc. It is further advisable in such cases 
to see to the quantity of food taken. The diarrhoea may be 
moderated by reducing the quantity of milk, and giving thin 
broth of chicken, veal, or mutton. Brand's essence of beef 
gives a large amount of nourishment in a form which one 
supposes is absorbed from the upper part of the intestines, 
and cannot leave much behind to worry the ulcerated surface 
below. 

Bismuth subnitrate and ipecacuanha wine are also of use, 
and so also the tincture of krameria, extract of logwood, and 
chalk mixture. 

For the bronchitis, a little ipecacuanha wine, with tr. 
camph. co. and syrup of Tolu, may be given. 

As regards treatment by the bath, Henoch makes some 
very practical remarks. The effects of cold bathing are 
more pronounced in children than in adults, and conse- 
quently the first bath is, in some cases, an experiment, and 
it may be followed by a gradually falling temperature, until 
a condition approaching collapse results. This may be ob- 
viated by the administration of wine before and after the 
bath, but more particularly by trusting to tepid rather than 
cold bathing, and by not prolonging the immersion beyond 
six or eight minutes. 



MALARIAL FEVER. 



29I 



CHAPTER XVIII. 



MALARIAL FEVER. 



Ague is not common in children, and its behavior is 
sometimes peculiar. For this reason it is likely to be over- 
looked. It may occur even in infancy, and enlargements of 
the spleen have been found at birth which have been sup- 
posed to be due to the malarial poison. But the disease is 
more usually seen in those of four years old and upwards. 
It may sometimes occur in typical form, with cold, hot, and 
sweating stages. But as a rule well-marked rigors and defi- 
nite periodicity are absent. Dr. West states that the place 
of rigors is taken by a condition of extreme nervous depres- 
sion, sometimes by convulsions. As other peculiarities he 
notes the long continuance of the hot stage, the absence of 
any distinct sweating stage, and a continuous form of malaise 
and even pyrexia. This description will show how easily 
malarial fever might be mistaken for some continued fever 
of doubtful nature ; an error all the more likely from the 
infrequent occurrence of the one disease, and the very com- 
mon occurrence of the other. The acme of the pyrexia, 
as in adults, may be very high (105 ), and possibly this fea- 
ture might in some cases convey a hint of the true nature 
of the disease. But more important, as I think, than these 
anomalies of the more typical symptoms is the necessity of 
recognizing that malarial anaemia is not uncommon — some- 
times associated with enlargement of the spleen, sometimes 
not — and that extreme anaemia may exist without any his- 
tory of pre-existing fever. Anaemia is a characteristic 



292 THE DISEASES OF CHILDREN. 

symptom of ague at all ages, but it rarely reaches such an 
extreme in adults as is sometimes the case in childhood. It 
is said to come on very rapidly. Enlargement of the spleen 
is a common disease in children in the malarial regions of 
the tropics. The spleen under such circumstances will 
attain an enormous size, and many children die from this 
cause. 

[As above stated the first and last stages of the disease 
are frequently not as marked as in adults. The first stage 
is often overlooked by the parents, but when the rigor is 
absent there are slight tremors or the face becomes shrunken 
and pallid and the lips and finger-tips livid. The second 
stage is much prolonged, while the third is usually very 
short and sometimes altogether absent. During the inter- 
val between the paroxysms the child does not regain its 
usual buoyant spirits, but remains dull, fretful and feverish. 
After the fifth year the disease presents about the same fea- 
tures as it does in adults.] 

Diagnosis. — This must be arrived at first of all by bear- 
ing in mind the possibility of the occurrence of ague, and 
next by inquiring into all the circumstances of the case. 
There are no means by which to distinguish the enlarge- 
ment of the spleen due to ague from that due to other 
causes. But as regards the anaemia, the skin has a simple 
or sallow pallor with a bluish tint of the lips, which may 
help to suggest the nature of the case. 

Prognosis. — Ague is difficult to eradicate thoroughly at 
any time of life. With this qualification, it answers to the 
same remedies as in adults. But the enlargement of the 
spleen may be troublesome and slow to disappear. 

Treatment. — Quinine and arsenic are the remedies to 
apply to. Quinine is usually taken readily by children — it 
may be given in sweetened milk or with syrup and liquorice. 
Arsenic should be commenced after the quinine is discon- 



MALARIAL FEVER. 



293 



tinued. Five or seven drops of the liquor arsenicalis* may 
be given in syrup of orange and water, three times a day 
after meals. It is often good to combine it with iron. With 
the syrup of the lacto-phosphate of lime and iron it makes 
a good tonic. 

* Fowler's solution. — Ed. 



2S 



294 THE DISEASES OF CHILDREN. 



CHAPTER XIX. 

DISEASES OF THE RESPIRATORY SYSTEM. 

The physiological differences in the respiratory organs 
between the child and the adult are numerous, and, as re- 
gards the examination of children, they are by no means 
unimportant. The breathing is diaphragmatic in children, 
and as it is difficult sometimes to detect the movement of 
the upper part of the thorax, it is very necessary to have 
the chest thoroughly bare for the purpose of examination. 
Infants under two years breathe quicker than adults, thirty 
or more to the minute, but above that age the respirations 
are at about the same rate as in older people, though quick- 
ening at very slight disturbing causes. Children, also, 
breathe irregularly; often paroxysmally ; after what maybe 
called a modified Cheyne-Stokes type. The Cheyne-Stokes 
rhythm consists of a series of short but gradually lengthen- 
ing inspirations culminating in a deep-drawn breath, from 
which in a descending scale the respiratory movements 
flutter down to an elongated pause ; and this type of respi- 
ration, though much modified, and its sharper characteristics 
destroyed, may often be seen in infants. Pauses in respira- 
tion are a feature of childhood, and they are particularly 
marked when the child is crying. To auscultate a chest at 
such a time requires the greatest patience, the pauses are of 
such long duration, but the information gained from the in- 
spiration at these times is peculiarly valuable, each long- 
drawn breath after the temporary arrest is so full and deep. 
Infants and children not only breathe irregularly, but they 
breathe often with asymmetry. It is quite a common thing 



DISEASES OF THE RESPIRATORY SYSTEM. 295 

to find a child breathing fully, now with this side, now with 
that, and unless this is ever present to the examiner he will 
be not unlikely to make mistakes when it comes to be a 
question, as so often happens, of the nature of the disease ; 
nay, even of the side upon which it is located. I take this 
to be due not to the muscular weakness, as some aver, but 
to the as yet imperfect education which is seen in all the 
muscles, whether of speech or of voluntary movement. 
Hence also the Cheyne-Stokes type of respiration, which is 
a paroxysmal one. Children work paroxysmally, whatever 
the movement in hand. The nervous discharge takes 
place, and then comes a pause — another discharge, and 
another pause — and so on ; and it is only as the nerve cen- 
tres reach a higher state of training that the discharges are 
so regulated as to become more continuous. I know a little 
child, and this is not uncommon, who learning to talk will 
carry on a conversation to the full extent of his knowledge 
of words, for a few minutes, and then he becomes quite 
fuddled for a while, and after a rest, on he goes again. The 
same child, if he is at all out of sorts, will stammer badly ; 
he becomes in fact aphasic intellectually, and his w T ord- 
memory is for the time exhausted — or his ill-nourished 
brain loses its discharging force, and acts intermittingly. It 
is but little otherwise with the respiratory centres, they act 
irregularly, and soon become exhausted. 

A point or two connected with the physical examination 
of the chest may next be mentioned. Percussion is ahvays 
to be gentle — apart from the reason that there is the likeli- 
hood of frightening the child, heavy percussion may lead to 
quite an erroneous conclusion. It will often elicit resonance, 
whereas the note is really dulled. This more readily occurs 
in dealing with fluid in the chest, and is probably due either 
to the heavy percussion displacing the fluid — bringing the 
stroke down upon air containing lung beneath — or else to 



THE DISEASES JF CHILDREN. 

the greater readiness with which, in young subjects, the 
stroke is transmitted to other and sounder parts of the lung. 
The chest of a child is said to be more sonorous than that 
of an adult — all that this means is that a more resonant 
note is more easily elicited ; and all that this can mean in 
turn is, that the percussion acts upon the lung more readily. 
Probably this is largely due to the more yielding nature of 
the ribs in young people, and to a thinner covering of soft 
parts over them. 

Again, it is not difficult to obtain a dull note which is not 
due to the condition of the lung underneath. A very little 
difference, for instance, in the level of the two shoulders will 
effect this, and the irregularity of respiration so noticeable 
in children will do the same. Therefore, in cases where the 
differences are slight, it is always as well to be cautious in 
our opinion, and probably to wait until a second examina- 
tion has confirmed or negatived the original conclusion. 

Percussion should be carried out by one finger laid fir: 
on the chest, and one or two fingers tapping it vertically, 
slowly and lightly With these precautions, a good reso- 
nant note ought to be elicited anywhere, although, as in 
adults, the apices and scapular region van' much in differ- 
ent children. I see no reason for confining the examination 
to the back, or for postponing percussion until after auscul- 
tation. There is but little difficulty with children if they 
are left unrestrained and the percussion is gentle. It is 
usually well to commence with the examination of the back, 
so that, if the child is shy, the more important part of the 
examination may be conducted out of sight; but in a very 
large number of cases it is perfectly easy to even auscultate 
the front of the chest if the examiner sets to work with pa- 
tience, and allows a child to play with the end of the stetho- 
scope at intervals. Nor do I agree that auscultation is better 
conducted by the ear than by the stethoscope. The chest 



DISEASES OF THE RESPIRATORY SYSTEM. 297 

diseases of children are so apt to be partial in their distribu- 
tion, and the accommodation of other parts of the lung is 
apt to be so much more perfect, that it is very necessary to 
go over the chest carefully inch by inch, to compare the 
corresponding sides of the chest, and to trace the intensity 
of the respiratory murmur from one side to the other. The 
ear covers too extensive a surface, and — taking in too much 
at a time — is thus likely to miss a small patch of consolida- 
tion or the deficient expansion which occurs so often. The 
student will have many a difficulty also with the quality of 
the respiratory murmur. He is usually told that the child's 
respiration is puerile — that is, that the inspiratory murmur 
is very harsh ; the expiratory being but little altered. But, 
as a fact, his most frequent difficulty will be to know whether 
he is dealing with bronchial breathing which is the result of 
disease, or with that which is due only to a temporarily ac- 
celerated respiration. In young children the expiratory 
murmur in the upper two-thirds of the back is frequently of 
a bronchial nature — longer than it should be, higher pitched 
than it should be — and the question of the meaning of this 
can only be settled by close examination of both sides and 
an appeal to one's experience. The observer should pay 
special attention to the pitch of the expiratory murmur, this 
being the best criterion of the nature of the sound. If it be 
not only long, but persistently of high pitch, it is well to be 
cautious. As another hint, I would say this : If the tubular 
breathing is of exactly the same quality on both sides, doubt 
your diagnosis, should you have decided that it means dis- 
ease. It is so likely under these circumstances to be a 
tracheal respiration, transmitted, either from exaggeration on 
its own part, or too little damping by the vesicular murmur 
in a small chest. [Puerile need not be confounded with 
tubular respiration. The former has for its distinctive char- 
acter intensity; in other respects there is no alteration. 



298 THE DISEASES OF CHILDREN. 

Tubular or bronchial breathing, on the contrary, while it 
may be intense is otherwise anomalous. Thus the inspira- 
tory element is shortened, there is a distinct interval of 
silence between it and the expiratory sound and the latter 
is higher pitched, louder, and more prolonged ; features 
exactly the reverse of healthy breathing.] As regards this 
necessity for careful comparison of the two sides of the 
chest, pleurisy and pleuritic effusion are very liable to mis- 
lead. Pleuritic effusion controls the action of the lung on 
the diseased side, but hardly otherwise alters the quality of 
sound, except at the apex, where it often compels tubular 
breathing; thus it happens that listening over fluid, the res- 
piration is soft and vesicular, and may seem natural, whilst 
an examination of the other side discloses what seems to be 
an excessively harsh and abnormal sound, of doubly puerile 
character, if so we may express it. Thus, the report is made 
that the sound side is diseased and the diseased side healthy. 
This is quite a common occurrence, and can only be avoided 
by paying exclusive attention to no one sign in particular, 
but by examining both sides of the chest throughout — not 
only by auscultation, but by percussion also — and by a care- 
ful scrutiny of their movements. With these few hints, we 
may pass to the consideration of special diseases, and there 
seems no reason for departing from the natural arrangement 
of working from above downwards. 

The Nose. — There are some children who are always 
" catching cold." This means that they begin to sniffle, and 
gradually a copious, glairy, and thin mucous discharge makes 
its way from the anterior nares. This state may last several 
days, the upper lip ultimately becoming excoriated and sore 
from the discharge and its frequent removal combined. 
During all this time the child is usually fretful, often fever- 
ish, thirsty, and without much appetite. Its nights are also 
frequently disturbed, for young children breathe so much 



DISEASES OF THE RESPIRATORY SYSTEM. 



299 



through their nose, that the existing state of things prevents 
the natural respiration. Stand over the cot of a child with 
a " cold," and you will hear it sniffling away with quickened 
respiration, and then suddenly waking up and crying, tossing 
itself down on to the pillow again, and so on repeatedly. 
These cases run their course, so far as the nose is concerned, 
in two or three days ; but they are frequently succeeded by 
a cough, due, no doubt, to the extension of the catarrh along 
the mucous membrane to the posterior nares, tonsils, and 
fauces, and occasionally down to the epiglottis or rima as 
well. A cold, therefore, if severe, requires care, as at any 
time it may extend and set up a general bronchitis, or even 
laryngitis. 

Causes. — Whether colds are due, as is thought, to chills, 
or to atmospheric-borne germs, and so on, it would perhaps 
serve no useful purpose to discuss. But it is of practical 
import to remember that in many cases they are unques- 
tionably contagious. They are also frequent concomitants 
of dentition. 

Coryza should also be remembered as heralding often the 
advent of measles, and as being sometimes associated with 
diphtheria, generally, though not always, with its more fatal 
forms. 

Ozsena. — In unhealthy children, particularly the scrofulous 
and syphilitic, nasal catarrh is liable to become chronic. 
The swollen mucous membrane becomes excoriated or 
deeply ulcerated, and in the most prolonged cases the bone 
may become exposed and die. In any case there is likely 
to be ozaena, as the secretion is not merely mucoid, but 
purulent and bloody. It crusts upon the surface of the 
mucous membrane, becomes decomposed, and thus the fetor 
which is so characteristic and so loathsome. The sense of 
smell often becomes destroyed in the worst cases, a happy 
thing for the afflicted child. 



300 THE DISEASES OF CHILDREN. 

Treatment. — For simple catarrh very little treatment is 
necessary. Children from a few months old up to three or 
four years are those that give the most trouble, and perhaps 
from nine months to two years is the age at which colds are 
liable to be most severe. The child must be kept in one 
room at an even temperature, in bed if it is very feverish or 
fretful, and some saline may be given it, such as the citrate 
of potassium and a little fluid magnesia to act upon the 
bowels, if necessary. It is generally as well to give a sleep- 
ing draught at night of bromide of potassium and hydrate 
of chloral, five grains of the one, and half a grain or a grain 
of the other. West remarks that an intractable catarrh 
is sometimes cured by gray powder, even though there 
may be no evidence of the syphilitic taint, and my own 
smaller experience certainly corroborates this. In the 
chronic cases two ends have to be kept in view, the build- 
ing up of an unhealthy body, and the cure of the diseased 
mucous membrane. The local treatment is usually neglected 
in whole or in part. The parents will make their children 
take any quantity of medicine, but they will not take the 
trouble to secure efficient local applications ; and, unfortu- 
nately, local applications are of the first importance. The 
chief object of these is to keep the surfaces moist and sweet; 
the disease is so troublesome, because the discharges crust 
on the surface and become offensive, and thus in the various 
movements of the nose the mucous membrane beneath the 
crusts and at their sides cracks and bleeds. Therefore an 
antiseptic must be applied to keep the parts sweet, and 
glycerine or oil added to it to keep them supple. A com- 
bination of iodoform, eucalyptus oil and glycerine makes 
a nice and effective preparation (F. 40), or an ointment in 
which vaseline is substituted for the glycerine may be used 
instead. The glycerinum boracis, or glycerine and boracic 
acid, are also useful preparations. But whatever be used, 






DISEASES OF THE RESPIRATORY SYSTEM. 



301 



it is essential that it be applied freely and frequently, and 
this is not easy of accomplishment. Sometimes astringents, 
such as equal parts of glycerine and the glycerine of tannic 
acid; or that and sulphate of zinc, in the proportion of two 
grains to each ounce; syringing with permanganate of potas- 
sium, or with a borax and bicarbonate of sodium lotion, are 
very useful in older children. But the difficulty of local 
application is greatly enhanced, if not altogether impossible, 
in young children when the syringe comes to be used. 
The best way of syringing the nose is undoubtedly the 
hydraulic method — an india-rubber tube, leading from a 
small cistern or jug containing the lotion, and placed at the 
requisite height, plays the part of a siphon. The nose- 
piece is placed in the nostril, and a most perfect syringing 
is thus accomplished. But very young children are much 
frightened by this. The sensation produced by the water 
in the nose is not pleasant, and some of the fluid runs down 
into the pharynx and interferes with respiration. Moreover, 
the operation, to do it properly and cleanly, requires the 
attention of three people — one to take the child, one to col- 
lect the water that flows from the nose, and the third to 
manage the douche. Therefore this treatment is not often 
carried out thoroughly, and it is necessary to trust to the- 
thorough application by a brush of the remedies already 
mentioned. It is more practicable with older children; and, 
with them, in addition to other measures, a plug of iodized 
cotton-wool should be kept in each nostril. For general 
treatment these children require good food, milk, cream, 
good air — particularly, bracing seaside air — -and iodide of 
iron, cod-liver oil, maltine, stout, etc. 

[While nasal catarrh is a trifling disease in children who 
have cut their teeth and been weaned, it is serious in nur- 
sing infants, because it greatly interferes with alimentation 
by preventing nasal respiration, a necessity during the act 

26 



302 THE DISEASES OF CHILDREN. 

of sucking. The danger is increased proportionately to the 
length of the attack. In obstinate cases, in addition to 
keeping the nose clean, by frequent swabbing, and thor- 
oughly anointed externally and internally with vaseline, it is 
well to make the patient wear constantly a light flannel cap. 
This plan was suggested by Dr. Charles D. Meigs, and 
sometimes it seems impossible to effect a cure without it. 
The cap should be removed slowly by cutting away a small 
piece at a time ; in this way the risk of a relapse from tak- 
ing cold is avoided.] 

The greatest perseverance is necessary in the treatment of 
ozaena. 

Epistaxis is a very common affection in childhood, and 
under conditions so varied that it is impossible to enumerate 
them all. Some children suffer again and again, whenever 
they are out of sorts, and this without any tendency to 
bleeding elsewhere. It is one of the commonest forms of 
haemophilic outbreak, and is also, as might be expected, a 
symptom of purpura from any cause. But perhaps it is 
more noteworthy as most frequently ushering in some acute 
disorder, be it one of the exanthemata, typhoid fever, per- 
tussis, acute pneumonia, or nephritis. 

It but seldom requires treatment save it be the outcome 
of haemophilia. Should it do so, the ordinary rules for the 
arrest of bleeding will at once suggest themselves — viz., ice 
to the nostrils, cold applications to the face and neck, and 
an inflation of tannin or matico snuff. 



LARYNGEAL SPASM LARYNGITIS —WARTY-GROWTHS, ETC. 303 



CHAPTER XX. 

LARYNGEAL SPASM— LARYNGITIS— WARTY-GROWTHS— FOREIGN 
BODIES IN TRACHEA, ETC. 



Catarrhal Spasm — Pseudo-Croup. — " My child is very 
subject to croup," is a common tale of a mother to the doc- 
tor; and as when a patient states that he or she has had a 
weak heart for years the medical man knows it to be the 
exception to find any organic disease, so here, the croup of 
domestic medicine is not the croup of the nomenclature of 
disease. Here is such a case : A boy, aged five and a 
half. He had a croupy cough three months ago, but got 
well in a day or two with some castor-oil. He had been 
quite well since until the day before he came to the hospital, 
when the cough had returned. He had a loud brassy cough 
but no dyspnoea, and seemed otherwise quite well. The 
fauces were injected and the tonsils large. Some castor- 
oil was administered and a simple expectorant, and he was 
well in a day or two.' The mother had already lost one 
child by true croup — tracheotomy having been performed 
in the hospital — and she was therefore very anxious about 
the symptoms in this case. 

Henoch gives one of the best and most natural accounts 
of this affection with which I am acquainted. These chil- 
dren have usually been the subjects of repeated attacks of 
subacute tonsillitis, and they have enlarged tonsils. This 
condition of parts is usually accompanied by a more or less 
fleshy or swollen state of the palate and mucous membrane 
around the laryngeal orifice, and, as a result of some fresh 
but often slight catarrh, the ary-epiglottic folds become im- 



3O4 THE DISEASES OF CHILDREN. 

plicated," and some slight glottic spasm occurs. The child 
has usually had a slight " cold," perhaps wakes up suddenly 
at night with an ugly laryngeal " brassy," " clanging," 
" croupy " cough, and perhaps with some temporary diffi- 
culty of breathing. This soon passes off, and it lies down 
to sleep again, breathing without discomfort, as soon as the 
fright of the awaking has passed off. This shows that the 
essential of the laryngeal trouble is spasm. The cough 
remains " croupy" for a day or two, and then disappears. 

Diagnosis. — This is arrived at by giving attention to the 
following features : The tendency to recurrence which these 
attacks evince ; the pre-existence of a cold or cough ; the 
presence of large tonsils. In the attack itself, there is the 
absence of persistent inspiratory stridor, the unchanged cry, 
and the speedy subsidence of the momentary inquietude — 
nothing remaining, in fact, but the cough. All these things 
tell of the absence of any material obstruction, and in favor 
of a temporary laryngeal spasm, provoked by some catar- 
rhal state of the upper laryngeal orifice. At the same time, 
as a word of caution, it may be remarked that it is only 
natural to suppose that a condition of this kind, if neglected, 
might readily pass on into an attack of definite laryngitis ; 
and, no doubt, care is requisite lest, in treating such an 
attack as of no moment, we should find that an exceptional 
case might prove in the issue to be one of true croup. 

Treatment. — The croupy cough is one that invariably 
causes anxiety to the mother, and there is therefore but 
little risk of such cases being neglected. But the treatment 
should be decided, nevertheless. The child must be kept 
to its bed until the cough has assumed a less menacing 
sound, and the room must be kept warm and the air moist 
by means of a bronchitis-kettle. Poultices or warm fomen- 
tations are to be applied to the throat, and some expecto- 
rant is to be given frequently. Tr. benzoin, co., ffUc; syrup. 



LARYNGEAL SPASM— LARYNGITIS — WARTY-GROWTHS, ETC. 305 



scillae, 5ss. ; ext. glycyrrh. liq., 5ss. ; aq. ad 5ij, may be 
given frequentty, or some similar combination of expecto- 
rants. Subsequently, the treatment of the tonsillar enlarge- 
ment becomes again prominent, but this is discussed in its 
proper place. 

I have called this condition catarrhal spasm rather than 
pseudo-croup, not for the purpose of inventing a new name, 
but because it suggests the nature of the chief features of 
the disease, and because it is in harmony with a series of 
other spasmodic affections of the larynx which occur in 
childhood, and which I now pass on to mention. These 
are — 

1. Direct Spasm, or crowing of con- 
vulsive nature, often rachitic. 

2. Reflex Spasm, or dyspnoea, due to 
spasm of the larynx, incited by 
enlargement of the mediastinal 
glands. 

3. Infantile Spasm, orthe crowing due 
to a congenital valvular forma- 
tion of the upper orifice of the 
larynx. 



Laryngismus. < 



An objection may perhaps be taken to such an arrange- 
ment, that it exalts a symptom at the expense of the cause, 
and thus tends to destroy the more stable basis of classifica- 
tion — that of structural change. This has no doubt been 
felt by other writers, and has led them to treat of laryngis- 
mus amongst diseases of the nervous system. But laryn- 
gismus is so essentially laryngeal that in this symptom lies 
most of its interest, both as regards theory and practice. 

Direct Spasm of the Glottis is one form of laryngismus 
stridulus. I call it direct, because being largely associated 
with rickets, a complaint, which, by the convulsive affections 



306 THE DISEASES OF CHILDREN. 

which attend it, indicates a state of instability of brain — it 
may be regarded, so to speak, as centrally ordained. 

Some, perhaps, may still prefer to consider it a reflex 
spasm. But if so, the discharging stimulus is so frequently 
varied that it is impossible to fix upon it with any precision, 
and in the majority of cases all that can be said is — this is 
laryngismus, and the child is rickety. Of its convulsive na- 
ture, in many cases, there can be no doubt: it is frequently 
associated with convulsions, and not uncommonly with 
tetany as well. Of thirty cases of laryngismus now before 
me, eight had had convulsions, two others carpo-pedal con- 
tractions. Dr. Gee notes that nineteen of fifty of his cases 
had had eclamptic fits. Laryngismus is so frequently asso- 
ciated with rickets that, again appealing to Dr. Gee,* we find 
him stating that spontaneous laryngismus is always asso- 
ciated with that disease — forty-eight of his fifty cases being 
unquestionably so. Twenty out of thirty-four of my own 
cases were also rachitic. I have not noticed the association 
of laryngismus with craniotabes — that condition of skull in 
which the bones yield under pressure with the crackle of 
parchment — but this has been remarked upon by several 
observers. 

Many have held that dentition is the exciting cause of the 
laryngeal spasm in these cases, and no doubt the disease 
occurs about the time the teeth are commencing to make 
their appearance. All the thirty cases alluded to were under 
two years of age ; and most of them were under a year, 
from the eighth to the eleventh month being the favorite 
period. One other point must be alluded to — viz., that the 
disease is much more prevalent in the first than in the second 
six months of the year. For this observation we are again 
indebted to Dr. Gee.f Of sixty-three cases spread over 

* On Convulsions in Children : St. Barth. Hosp. Reports, vol. iii , 1867. 
I On Laryngismus: St. Barth. Hosp. Reports, vol. xi., 1875. 



1 






LARYNGEAL SPASM LARYNGITIS WARTY-GROWTHS, ETC. 307 

three years, fifty-eight occurred from January to the end of 
June, and only five from July tQ December. Dr. Gee very 
reasonably supposes that inasmuch as teething and gastro- 
intestinal complaints, which are well-known producers of 
convulsions, are prevalent all the year round, the weather 
must in this instance be at fault. But not directly so. Dr. 
Gee attributes the disease to a nervous erethism begotten 
by close confinement to ill-ventilated rooms ; and this idea 
is, I believe, well worthy of consideration. 

Infantile Spasm. — There is a class of cases met with in 
the out-patient room in no inconsiderable numbers, in which 
there is laryngismus of a mild type, but so persistent as to 
make it clear that some local laryngeal fault exists. Such 
children may show no evidence of rickets — no tendency to 
convulsions — although, seeing that rickets is a disease so 
prevalent, it is not to be wondered at that slight evidences 
of it may exist in some of these cases. The respiration in 
these cases is more reedy than in most of the cases of direct 
or spontaneous spasm, and it is more persistent, being even 
to some extent present during sleep. Nevertheless, it is 
distinctly aggravated, and to this extent spasmodic, under 
any excitement. The history of these cases is that whenever 
excited — on suddenly awakening from sleep, when they are 
suddenly taken from a warm to a cold atmosphere, when 
they cry, sometimes when their position is suddenly changed, 
or when from sitting up they are placed in bed — a croaking 
noise is made as if the child were going to choke. I have 
long thought that these cases must result from the confor- 
mation of the upper part of the larynx in early infancy. I 
had supposed that at this time of life the larynx was too 
yielding, and that when a rush of air was produced by means 
of deeper or more hurried breathing than usual, it could not 
pass fast enough. It seems probable, however, from an ob- 
servation made by Dr. Lees, that it is not so much a yield- 



308 THE DISEASES OF CHILDREN. 

ing of the parts as a natural condition which exists in some 
cases. Dr. Lees made an inspection of one of these cases 
which had died from other causes, and he found that the 
epiglottis was excessively recurved in its vertical axis — as if 
it had been bent in half down the middle, and that thus the 
ary-epiglottic folds were brought almost into apposition, and 
a mere chink left between them. Now, more or less of this 
recurvation of the epiglottis is a common thing in infancy 
and early childhood, and I can quite believe that some such 
condition as this may explain some of the cases of laryngis- 
mus, which would otherwise be swept into the net of con- 
vulsive laryngismus on account of the coexistence of a very 
moderate rachitis. The history of so many of these cases is 
that they breathe quite naturally until they begin to breathe 
hurriedly ; but as soon as this happens, no matter what the 
cause, then there is dyspnoea and crowing. And more than 
this, these cases are very little, if at all, relieved by treat- 
ment, and the symptom gradually passes off as the child 
grows older. 

Reflex Spasm, due to excitement or worry of the medi- 
astinal branches of the vagus, is, without doubt, a real oc- 
currence ; but it has. to some extent, got into bad odor from 
the fact that some authors have endeavored to make all lar- 
yngeal spasm, apart from actual laryngitis, due to this cause. 
Thus, we have the spasm of pertussis due to bronchial gland 
enlargement, thymic asthma from engorgement of the thy- 
mus, and other conditions due to other forms of mediastinal 
trouble. This view does not appear to me to be tenable. 
Mediastinal affections have their sphere in the provocation 
of laryngeal spasm, but not to the exclusion of other causes. 
I have seen laryngeal spasm associated with cheesy bron- 
chial glands, with cheesy bronchial glands softening, with 
suppuration in the mediastinum from other causes, with 
fleshy swelling of the mediastinal glands from acute inflam- 



LARYNGEAL SPASM — LARYNGITIS — WARTY-GROWTHS, ETC. 3O9 

niation, and even with a swollen condition of the thymus. 
Something of the same kind, too, occasionally occurs in as- 
sociation with acute pericarditis and pleurisy. It is no argu- 
ment against the potency of these conditions that they are 
not always, or even mostly, effective in producing the spasm. 
All convulsive affections are so largely due to individual 
proclivity, to disorderly nerve discharge, that no doubt a 
personal element is requisite as well as the local condition ; 
but that the local condition is sometimes associated with 
laryngeal spasm, distinguished by associated symptoms 
which allow of a correct diagnosis, there can, I think, be no 
doubt. 

Symptoms. — The classical laryngismus is thus described 
by West : " The child throws its head back, its face and lips 
become livid, or an ashy pallor surrounds the mouth, and 
slight convulsive movements pass over the muscles of the 
face. The chest is motionless, and suffocation seems im- 
pending. But in a few moments the spasm yields, expiration 
is effected, and the crowing inspiration succeeds/' Others 
depict it in still more alarming terms. But of a disease of 
this severity I know but little. A large number of infants, 
most of them nine or ten months old, are brought to the out- 
patient rooms of hospitals. Some are very rickety ; more 
are but moderately so ; and some are not evidently rachitic 
at all. Sometimes there is a history of convulsions of one 
kind or another. But the child is usually in moderate or 
good health; all that is supposed to ail it is that as soon as 
it is the least excited — no matter what the cause — a fit comes 
on, and it is unable to get its breath ; and this is followed 
by a long-drawn inspiratory crow, of a similar character to 
that of pertussis, only not being preceded by such violent 
paroxysmal emptying of the chest by cough — it is, of course, 
less violent, noisy, and prolonged. There may be a wheeze 



3IO THE DISEASES OF CHILDREN. 

in its character which, as West says, is something between 
the whoop of pertussis and the stridor of true croup. 

The crow over, there is perhaps a fit of crying, and the 
child returns quickly to its natural playful habit, or else it 
remains fretful and out of sorts, with a continuance of carpo- 
pedal contractions, perhaps until there is a general convul- 
sion or the attack slowly passes off. 

The spasm due to an infantile conformation is not, by any 
means, easy to distinguish clinically ; but the cause being 
persistent, the dyspnoea will be more or less continuous, and 
slight inspiratory crowing will often occur two or three times 
during one inspiration. The inspirations may be of a more 
reedy or croaking character, and the crow is less associated 
with rickets — less of a convulsive affection — the child can 
hardly be said to be much, if at all, distressed by it — and it 
is less amenable to treatment. 

Reflex spasm is sometimes, one hardly dare say generally, 
associated with more or less persistent wheezing, as if from 
general bronchitis. Thus, such cases are liable to be mis- 
taken for spasmodic asthma. Asthma may occur, and very 
severely in children; but the possible existence of some en- 
largement of the bronchial glands should always be in mind 
in such cases. Cough is another symptom of great value ; 
there may be a persistent laryngeal tone about it which is 
peculiar, and it may be paroxysmal, and so make the parent 
think the child must have whooping-cough. The likeness 
to pertussis is sometimes further increased by the occurrence 
of vomiting after the cough. Hoarseness is sometimes 
present. These features should be remembered after severe 
and prolonged attacks of pertussis, and the attention turned 
to the possibility of the existence of some bronchial gland 
enlargement. 

Prognosis. — Most writers allude to a considerable risk 
which is supposed, by some, to attach to laryngismus, but it 



LARYNGEAL SPASM — LARYNGITIS WARTY-GROWTHS, ETC. 3 I I 

is clear that no definite opinion can be formed upon this 
point by using so vague a term. If laryngismus be due to 
a variety of causes, some may be dangerous, others not. 
This, I think, is how the case stands — a spasm of the glottis 
due to convulsions will necessarily be dangerous, because all 
convulsions in young children are attended with risk of 
sudden death ; and, in the same way, the reflex spasm, due 
to enlargement of the bronchial glands, or excitement of the 
peripheral branches of the nerves in the mediastinum, are 
dangerous, because the cause is a more or less persistent 
and usually an organic one ; but the other forms are, at any 
rate, less dangerous. To that form of spasm which is due 
to infantile narrowing of the glottic aperture, I should say 
hardly any danger attaches, and little more to the catarrhal 
spasm, although I suspect that this disease is more closely 
allied to, or rather more liable to run into, true laryngitis 
and croup than is usually taught. It is, in fact, the milder 
form of laryngitis, which at the other end of the scale shows 
as croup — the distinction between the two extremes of the 
scale being the somewhat arbitrary one of quick recovery in 
the one case and not in the other. 

Treatment. — Catarrhal spasm has already been dealt with. 
For infantile spasm but little can be done, save, perhaps, to 
give tonic medicines, and await the growth of the child and 
the fuller development of the larynx. 

The direct spasm, associated as it is with rickets, dentition, 
and general convulsions, must be watched and treated care- 
fully. If there be any tendency to general convulsions, as 
indicated by carpo-pedal contraction, etc., the bowels should 
be freely opened by a couple of grains of calomel, or syrup 
of senna, cathartic acid, jalapine, cascara sagrada, or what 
not. The first named is as good, or perhaps better than any. 
After the bowels have acted well, bromide of potassium, or 
sodium, or ammonium, in three to five grain doses, is to be 



312 THE DISEASES OF CHILDREN. 

given, with some syrup of Tolu and aqua anethi, three times 
a day. The bromide may be combined with half a drachm 
of the syrup of chloral, and subsequently, when the imme- 
diate tendency to convulsion has passed away, the syrup of 
the lacto-phosphate of lime and iron, or Parrish's food, or 
steel wine and cod-liver oil, should be given regularly for 
some time. The greatest attention must be paid to the 
ventilation of the rooms inhabited by these children. Rach- 
itic laryngismus requires no close confinement to hot and 
stuffy rooms, but plenty of fresh air, and the body is to be 
sponged with cold water regularly every morning. 

In the reflex spasm, all such things as will tend to reduce 
enlargement of glands must be adopted ; these are a pro- 
longed sojourn at the seaside; the inhalation of iodine; 
chloride of calcium in doses of four or five grains three times 
a day ; iodide of iron, and cod-liver oil given internally ; and 
possibly some local applications applied between the scapulae 
over the fourth and fifth dorsal vertebrae. 

Laryngitis in children maybe classified thus: 



Acute | Sim P le ' 

1 Membranous. 

Chronic (usually syphilitic). 



Acute non-membranous laryngitis is by no means un- 
common. It occurs with, or after, measles, whooping-cough, 
pneumonia, scarlatina, and diphtheria ; and also, amongst the 
lower classes at any rate, without any known cause, and it 
must be supposed, therefore, from simple exposure. I have 
notes of nineteen such cases, seven of which, being urgently 
ill, were admitted to the hospital, under the care of my col- 
leagues, Dr. Taylor and Dr. Baxter. They all got well with- 
out exception — most of them with the simple treatment of a 
steam tent. On looking over the admission book at the 






LARYNGEAL SPASM LARYNGITIS — WARTY-GROWTHS, ETC. 3 I 3 



Evelina Hospital, from 1874 to 1880, 1 find that about forty- 
five cases of laryngitis were admitted, twelve being called 
croup and diphtheria. To these I have added my own cases. 
The age which is most liable to the disease comes out with 
remarkable precision as from one to four years : 



Under 



Under . . . . . .6 

I 



14 

7 
4 



3 
10 



4 
17 

9 
o 



5 
5 

10 
3 



Of a series of sixty-one cases, thirty-six were girls, twenty- 
five boys. 

The following case is a fairly typical one : A girl, aged 
four years, had measles three weeks before she came to the 
hospital. Her cough had continued ever since, but she was 
not noticed to breathe badly until four days previously. 
The breathing had since then rapidly become more difficult. 
The child was livid-looking, with a noisy inspiration and 
expiration, and at the least disturbance the dyspnoea and 
the retraction of the thoracic walls was considerable. The 
tongue was furred; the temp. 101.5 ; the pulse very quick 
and irregular; no lymph could be seen on the fauces. She 
was admitted under Dr. Baxter, and placed in a tent and 
the atmosphere well steamed, and she quickly improved. 
Many similiar cases could be given. 

In the one or two cases that I have been able to examine 
laryngoscopically, the epiglottis has been, perhaps, a little 
swollen, and the ary-epiglottic folds also, but the visible 
changes were not- great. There is some difference of 
opinion as to the feasibility of using the laryngoscope in 
children. Some think the practice quite possible with 
patience, but I doubt whether laryngoscopy can be often 
available. 

[We agree with Steiner that simple laryngitis and pseudo- 



314 THE DISEASES OF CHILDREN. 

croup are but modifications of the same disease. In both 
the anatomical lesion is catarrhal in nature, in the former, 
however, the whole mucous membrane of the larynx is 
affected, in the latter chiefly that of the rima glottidis, the 
epiglottis and the ligamenta ary-epiglottica. 

It is also true that in severe cases of laryngitis, spasmodic 
attacks of difficult breathing or false croup are very apt to 
occur. This we have but recently seen in a case of acute 
laryngitis complicating rubeola. 

An attack may begin suddenly — usually at night — or 
may be preceded for a day or more by sneezing, running at 
the nose and huskiness of the voice or cry. When fully 
developed the voice is hoarse and rasping ; there is dry 
cough of a peculiar brazen tone, a sensation of tickling in 
the throat and hurried somewhat difficult breathing. These 
symptoms are worse or only present at night, when, too, 
there may be moderate fever. They last for three or four 
days ; when the cough becomes loose and recovery is 
rapid. 

In severe cases the voice is more brazen, and occasionally 
temporarily lost. The cough is harassing, paroxysmal 
and painful, the difficulty in respiration is more apparent 
and the movements are accelerated, and there is consider- 
able pyrexia with the usual frequent pulse, dry skin and in- 
creased thirst. It is in these that well developed paroxysms 
of pseudo-croup arise. The spasm occurs at night and 
wakes the patient in a fright from his sleep. The face, head 
and neck first flush deeply, then become livid, the eyes are 
staring and the breathing labored and stridulous as if suffoca- 
tion impended. The voice and cough are very hoarse or 
their sounds may be almost extinguished during the height 
of the seizure but soon return after it is over. The pulse is 
frequent, the skin hot and there is great restlessness and 
anxiety. These paroxysms last from half an hour to an 



LARYNGEAL SPASM LARYNGITIS —WARTY-GROWTHS, ETC. 3 I 5 

hour, and when the first occurs in the early part of the 
night it is apt to be followed by another, and unless mea- 
sures of prevention be used a repetition may take place on 
the next and even on the third night. The first is usually 
the most severe. Such severe attacks last somewhat longer 
than the milder ones, but the symptoms still show a tendency 
to remission or even intermission, being much lessened or 
disappearing during the morning or early afternoon.] 

Diagnosis. — This seems to me to be very aptly expressed 
by the old proverb, " the proof of the pudding is in the eat- 
ing." A child comes with symptoms such as I have narrated, 
and it is generally impossible to say offhand whether it has 
membranous or simple laryngitis. If no membrane can be 
seen on the fauces, and there is no local inflammation, no 
enlargement of the glands of the neck, but little fever, and 
no albumen in the urine, a fair hope may be indulged that 
the laryngitis is simple. No more can be said at first; the 
case must be allowed to unfold itself. But to show how 
impossible is a diagnosis sometimes, the student may be 
reminded that many a case thought to be croup has speedily 
recovered under a treatment of simple warmth and mois- 
ture ; that many another case, perhaps made light of at its 
commencement, has slowly matured into a fatal membra- 
nous laryngitis ; and — though it is hardly relevant, yet not 
wishing to lose any opportunity of insisting upon a point 
so important, I will further add — that as regards membra- 
nous laryngitis, assuming for the moment the non-identity 
of this form of disease and diphtheria, many a case thought 
to be the one has indubitably proved to be the other. 

Prognosis. — All cases of laryngeal obstruction require a 
cautious forecast for reasons just given, but no reliable 
opinion can be formed until the patient has been seen in 
bed, and after some hours of restriction to a regulated 
atmosphere of warmth and moisture. All such cases are 



316 THE DISEASES OF CHILDREN. 

naturally attended with risk so long as the breathing re- 
mains stridulous. But the dread symptoms will often 
quickly subside when the child is placed in a tent and the 
air steamed by the bronchitis-kettle, 

Treatment. — Of the first importance is a small tent not 
far from the fire, and from which a steam-kettle can be 
directed towards the patient. The child must not, however, 
be kept too hot — a temperature of 65 ° is not to be exceeded. 
Somewhere between this and 6o° will be proper. In warm 
weather, all that will be necessary will be a tent and the 
steam produced by means of a spirit-lamp placed under the 
kettle by the side of the foot of the cot. It is a good plan 
to medicate the vapor by some compound tincture of ben- 
zoin ; and, when there are suspicions of membranous in- 
flammation, the mixture of creasote and carbolic acid, 
recommended at page 231, is good. 

If the case is a severe one, it is well to give an emetic, 
and the simple powdered ipecacuanha root is at once harm- 
less and effective; five grains is usually sufficient ; a tea- 
spoonful of the wine may be given if it be preferred, and 
the dose is to be repeated if not successful within half an 
hour. Considerable relief to the breathing is often procured 
by this means ; and, by a judicious repetition of the emetic 
as the breathing becomes embarrassed, the pressing symp- 
toms are shortly quite relieved or kept at bay. In the 
meantime, however, it is well to give small doses of antimo- 
nial wine, five minims every two or three hours, and to act 
upon the bowels with a little hyd. c. cret, or calomel. In 
very severe cases, many recommend that four or six leeches 
be applied to the top of the sternum, and that a blister 
should be applied to the throat. I cannot regard either 
remedy with much favor. Emetics seem to me to be less 
dangerous and more reliable. Ice-cold compresses may be 
applied to the throat, and should all these means fail and 



LARYNGEAL SPASM — LARYNGITIS WARTY-GROWTHS, ETC. 3 I 7 



there be a risk of suffocation — as happens in the worst cases 
— tracheotomy must be performed. Upon this head, how- 
ever, it is worth saying that the student is often too urgent 
as regards operation. A child breathing stridulously no 
doubt requires most careful watching, but does not necessa- 
rily require an immediate operation. The larger number 
of cases of laryngitis, even with symptoms of some severity, 
are amenable to treatment, and therefore delay is always 
advisable until it be seen what effect the remedies may have 
upon the disease. Should an operation be resorted to, let 
me repeat that success will, in a large measure, depend 
upon the strict practice of the principles already advocated 
under the head of tracheotomy for diphtheria. 

Acute membranous laryngitis will not need much con- 
sideration here, as it would be only to repeat what I have 
said under the head of diphtheria. There are many who 
hold that all membranous laryngitis is diphtheritic ; others, 
who are equally dogmatic, that it is sometimes so, and some- 
times due to simple inflammation. And in this regard it is 
no doubt to some extent apposite that scalds of the throat, 
which are not very uncommon, seem liable to produce a 
membranous form of inflammation. But there are objec- 
tions to cases of this kind, because the local irritant acts by 
producing physical changes in the mucous membrane, some- 
times even to the boiling of the surface and the detachment 
of a slough. But there are extreme difficulties surrounding 
the subject on all hands. The diphtheritic poison is one 
which appears to originate under a variety of circumstances, 
the absence of which is seldom possible to prove; there are 
many cases of croup in which the existence of membrane is 
uncertain, yet they make part of the case in favor of an in- 
flammatory membranous disease when it is quite possible all 
the time that they may be cases of simple laryngitis. There 
is equally no doubt that many cases called croup at first, 

*1 



3 18 THE DISEASES OF CHILDREN. 

have proved to be diphtheritic by the fact that they have 
carried contagion ; and diphtheritic membrane may unques- 
tionably be confined to the larynx. The only ground upon 
which a distinction can be really maintained is that of clini- 
cal symptoms, but this is a ground which I do not feel dis- 
posed to yield. If in a long course of years a large number 
of most experienced men say that membranous laryngitis is 
sometimes attended with high inflammatory fever — at others 
with low fever, requiring the brisk administration of the 
strongest nutriment at frequent intervals and plenty of stimu- 
lant, I think we should be careful how we neglect such 
statements. Many different conditions will produce a pneu- 
monia, yet the pathological changes will be indistinguishable 
in one and the other. And so with membranous laryngitis. 
A similarity of local change is no conclusive argument in 
favor of a common cause, and I say if it can be established 
that at the bedside there are two groups of cases, the one 
with one set of symptoms and requiring antiphlogistic reme- 
dies, the other with another set and requiring other remedies 
of an opposite tendency, I for one should be inclined to 
trust to the symptoms as the best indication of the reality 
of the difference. The only doubt I have is whether in 
diphtheritic laryngitis the symptoms are, as is maintained,, 
markedly those of an asthenic or prostrating disease, as they 
certainly are in some of the worst cases of its tonsillar 
variety. 

Chronic Laryngitis is more often of syphilitic origin than 
due to other causes — sometimes it is a remnant of former 
membranous laryngitis. Various diseases are met with from 
simple hoarseness to considerable inspiratory stridor. 

I have a child under my care at the present time of eight 
or nine months old, who has had snuffles, rash, and ulcer- 
ating condylomata of the anus, and who is completely 
aphonic ; it cries with a hoarse whisper, and had at one time 



LARYNGEAL SPASM — LARYNGITIS — WARTY- GROWTHS, ETC. 3I9 

some dyspncea. This has subsided under mercurial treat- 
ment, but the loss of voice remains, and no doubt there has 
been considerable laryngeal disease. Another case, of a girl 
of four, I watched for a longtime; she was hoarse and 
breathed badly, and had a sunken nose. She gradually got 
worse, and tracheotomy became necessary. She also im- 
proved under mercurials and iodides, but the hoarseness 
continued, and she was ultimately lost sight of. I could 
give notes of several other cases which have been improved 
or cured by mercurials or iodides in the hospital or as out- 
patients. I must, however, mention two cases. One a male 
infant, aged four months, was admitted to the Evelina Hos- 
pital, and I saw it soon after its admission. It was one of 
six children. The mother had had three miscarriages. The 
child had had a sore mouth and snuffles for a month. It 
was pale and emaciated, with purulent ozaena, snuffles, ul- 
ceration of the tongue and mouth, and it had a hissing- 
aphonia with stridulous dyspnoea. Clean-punched deep 
sores were present about the anus and scrotum, and there 
were large brown discolorations in various places. The 
dyspnoea was very great, but the child was so emaciated and 
so young that no chance was offered of relief by opening the 
trachea, and it was therefore treated by mercurials alone. 
It died a short time after its admission, and at the autopsy 
a large vertical ulcer was found in the larynx at the base of 
epiglottis and perforating the thyro-hyoid membrane. 

The second case, a girl of four, was brought as an out- 
patient for noisy breathing, which had been getting worse 
for three months. She was a healthy-looking child, but 
breathed with a constant slight stridor which increased when 
she coughed or exerted herself. Her voice was but little 
altered, its pitch being slightly raised without loss of tone. 
There was a distinct elastic fulness of a peculiarly soft char- 
acter over the thyroid body, but no distinct enlargement of 



320 THE DISEASES OF CHILDREN. 

the body itself. The carotids were displaced outwards, and 
there was bulging of the posterior wall of the pharynx. 
She was under view for about three months, and Mr. Clement 
Lucas, who saw her with me, inclined to the view that retro- 
pharyngeal abscess existed with an enlarged thyroid. She 
was subsequently admitted under Dr. Taylor, and her 
breathing becoming worse, tracheotomy was performed, 
and she died not long after. The autopsy showed a large 
fatty tumor extending from the base of the skull down be- 
hind the pharynx.* With this case in view it may also be 
mentioned that an enlarged thyroid sometimes causes dysp- 
noea from pressing on the trachea, and that occasionally also 
the pressure of enlarged and caseous glands may do the 
same. 

Diagnosis. — This must be attempted rather by bearing in 
mind what are the possibilities, and by excluding those af- 
fections which in the particular case are contra-indicated. 
The symptoms of chronic laryngitis may be produced by 
syphilitic inflammation of the larynx, by warty growths in the 
larynx, by chronic thickening resulting from a bygone croup, 
or by extension of the disease from the mucous membrane 
around. It may also be simulated by disease outside, such 
as a retro-pharyngeal abscess or a new growth of any kind. 
But in this class of cases there is usually marked dysphagia, 
and there are likely to be peculiarities in the case suggest- 
ing that it is not a straightforward one of laryngitis. As 
regards the cases of pressure upon the trachea to which I 
have alluded, Gerhardt has stated that immobility of the 
vocal cords during the respiratory act is a symptom of pres- 
sure upon the trachea below the glottis ; this might possibly 
be of use when a laryngoscopical examination can be made. 

Of other conditions than these which cause laryngeal 

* This case has been published by Dr. Taylor in the " Trans. Path. Soc." 

1876-7. 



LARYNGEAL SPASM LARYNGITIS — WARTY-GROWTHS, ETC. 32 I 



dyspnoea, warty growths in the larynx and retro-pharyngeal 
abscess are perhaps the more important; but oedema glot- 
tidis may be occasionally met with, though I think but 
rarely, from the extension of inflammation from the tonsils 
or the mucous membrane of the nose and pharynx. Per- 
haps more common than any is a certain amount of obstruc- 
tion to the respiration from a general thickening and hyper- 
trophy of the pharyngeal mucous membrane — a state of 
things which I have seen several times. The mucous mem- 
brane under these circumstances is spongy and warty-look- 
ing — sometimes thrown into rugae, and altogether consider- 
ably narrowing the faucial passage. I have several times 
been puzzled in such cases to know whether I was dealing 
with this disease or with some retro-pharyngeal abscess, the 
complete examination of the throat in young children being 
a matter of so much difficulty. The pharyngeal conditions 
are described more in detail in their appropriate place, p. I IO. 

Prognosis. — This will, of course, depend upon the origin 
of the disease. So far as the dyspnoea is concerned, these 
cases do remarkably well. But one must be rather cautious 
in expressing an opinion as to the return of the voice, as the 
aphonia appears to be a less remediable condition. 

Treatment. — If the dyspnoea is at all urgent, and probably 
in any case, it will be advisable to try what a moist atmo- 
sphere will do, and either iodides or mercurials should be 
given internally. In very chronic cases, where the dyspnoea 
is considerable and intractable, it may be well to consider 
tracheotomy as a remedial measure. It certainly would 
seem that the continued action of a larynx, reduced to a 
mere chink, although sufficient perhaps for the purposes of 
aeration — not without discomfort — tends to perpetuate its 
own ill by keeping up spasm and augmenting the products 
of inflammation. Tracheotomy puts the parts at rest, and 
therefore favors their return to a healthy state. Moreover, 



322 THE DISEASES OF CHILDREN. 

although at no time would I counsel a resort to laryngotomy 
or tracheotomy until all other means of relief had been dis- 
cussed or exhausted, yet treated secundum artem y I believe 
that the operation is less dangerous in such cases than those 
in which it is performed for diphtheria, croup, or acute 
inflammation about the respiratory passages. 

Warty-growths in the larynx are rare, and their diagnosis 
very difficult; in one case, a child of about two, though 
examined by the most expert of laryngoscopists, and after 
tracheotomy, no diagnosis was arrived at. In another, an 
older child of four, the growths were seen in the larynx by 
the laryngeal mirror after tracheotomy had been performed. 
Lon^-standincr hoarseness and difficulty of breathing, unas- 
sociated with fever, and when syphilis or phthisis can be 
excluded, are very probably due to a new growth ; to say 
this is to give a very concise and practical summary of our 
means of diagnosis. Laryngeal warts always have a well- 
marked cauliflower-like aspect ; they are true warts or papil- 
lomata, and they grow from the surface of the true vocal 
cords, or from other parts of the larynx, usually below them. 

Treatment. — This must necessarily be a difficult matter. 
If the growths can be attacked from the mouth, they may 
be swabbed with chromic acid solution, or still better, per- 
haps, painted with some salicylic cream or salicylic acid in 
glycerine; and occasionally it is possible to remove them 
from above by operation. Two or three such cases are on 
record in children of such tender age as from three to five 
years. But in most cases the persistence of symptoms of 
chronic laryngitis ultimately leads to tracheotomy, and it is 
only after the operation that the throat becomes tolerant 
enough to enable anything to be done by the mouth. Pos- 
sibly the warts may then be removed by this channel ; they 
are easily detached if they can be reached. In several cases 
now on record, however, the continuance of dyspnoea has 



LARYNGEAL SPASM LARYNGITIS — WARTY- GROWTHS, ETC. 323 



led to the operation called thyrotomy ; the thyroid cartilage 
is slit up in the middle, the larynx opened, and the warts 
removed, some solution such as I have named being applied 
to the diseased surface afterwards, and the parts again care- 
fully adjusted and secured by sutures. This was done three 
or four times in a case under the care of my colleague, Mr. 
Davies-Colley, and with ultimate success, and the boy was 
still well eight years later, save that he could only talk in a 
hoarse whisper. 

The operation of tracheotomy for these growths has been 
performed, according to Gerhardt, fourteen times — six suc- 
cessfully at the ages of fifteen, eleven, six, six, five and a 
half, and three and a half years ; the remainder unsuccess- 
fully at the ages of eight, three, three, two and a half, two 
and one-third, and two ; and from these data the conclusion 
is drawn, which is probably a sound one, that the younger 
the child the greater the risk from operation. Thyrotomy 
has been performed in twenty-one cases, but the results do 
not appear to have been very successful if we take into ac- 
count that some patients died, and that in many the growths 
recurred, necessitating, in some cases, a repetition of the ope- 
ration. Nevertheless, it should be performed when other 
means have failed. 

Foreign bodies in the trachea, if not expelled by cough- 
ing, will require surgical treatment, and probably trache- 
tomy. They produce more or less general bronchitis and 
paroxysmal attacks of urgent dyspnoea. The history of these 
paroxysms is no doubt that the body, usually a pea or some- 
thing round, is^drawn into the trachea and plugs the bron- 
chus. There it remains for a time until the mucous secre- 
tion set up by its presence induces a more than usually 
violent fit of coughing. This dislodges the body and drives 
it into the upper part of the trachea, perhaps into the larynx 
below the cords, where the irritation provokes spasm. By- 



324 THE DISEASES OF CHILDREN. 

and-by the body falls down again into its former spot and 
the spasm subsides, to be again renewed until expulsion of 
the body is procured or broncho-pneumonia is set up by the 
worry of its presence. But there is a further point upon 
which I would insist — viz., that if the foreign body becomes 
fixed in the bronchus, there will probably be no paroxysmal 
dyspnoea. And it is not uncommon for fish-bones and other 
bodies to become fixed in one or other bronchus — usually 
the right — and there to set up a unilateral bronchitis, the 
cause of which may be puzzling and overlooked unless the 
possibility be borne in mind. Numerous cases are on record 
of pieces of bone, wheat-ears, etc., becoming impacted in the 
bronchus, and thus setting up a fatal pneumonia. Dr. Wilks 
has published a case in which an ear of grass worked its 
way down the bronchus to the surface of the lung, there set 
up an empyema, and was discharged by the opening made 
for the evacuation of the pus. 

Treatment. — Foreign bodies may be expelled by cough- 
ing, or by emesis. Their expulsion has sometimes been 
apparently favored by holding the patient up with his head 
downwards ; but tracheotomy is often necessary, and the 
prognosis in such cases is not favorable unless the body is 
quickly expelled. Mr. Durham has successfully performed 
thyrotomy in one case, a cherry-stone being impacted in the 
larynx. 

[Dr. H. R. Wharton, one of the surgeons to the Chil- 
dren's Hospital, Philadelphia, has recently reported three 
cases in which tracheotomy was successfully performed for 
the removal of foreign bodies from the tracrjea and larynx. 

The first case was a boy, aged seventeen months, a patient 
at the Children's Hospital. After the production of anaes- 
thesia, the trachea was exposed and laid open, when a forci- 
ble expiratory effort occurred and a small white bean was 
expelled from the wound. A small silver tracheotomy tube 



LARYNGEAL SPASM LARYNGITIS — WARTY-GROWTHS, ETC. 325 



was inserted as a matter of precaution. The child did well 
after the operation. The tube was permanently removed on 
the fourth day and he was discharged, the wound having 
entirely healed, two days later. 

The second case, a boy, aged nineteen months, was ad- 
mitted to the hospital on May 3d, 1883. Four days before 
he accidentally inhaled a portion of a grain of gourd-seed 
corn, and was at once seized with violent coughing and 
dyspnoea. When admitted the symptoms were so urgent 
that immediate tracheotomy was deemed necessary. Dur- 
ing the operation, which was performed without anaesthesia, 
the respiratory movements ceased and artificial respiration 
had to be resorted to. This was kept up for some minutes 
and hope of resuscitation had almost vanished, when sud- 
denly a voluntary respiration occurred bringing the foreign 
body into the wound, whence it was removed. Afterwards 
respiration was performed freely so long as the tracheal 
wound was kept open by retractors, but so soon as these 
were removed and the edges fell together dyspnoea came on; 
consequently a small tracheotomy tube was inserted. The 
operation was followed by no unfavorable symptoms, the 
patient quickly recovered and was quite comfortable while 
wearing the tube, though the recurrence of dyspnoea ren- 
dered its removal for any length of time impossible until 
July 23d, eighty-one days after its insertion. 

Besides early age there are two other features of interest 
in this case, namely, the respiratory arrest after opening the 
trachea, and the delay experienced in removing the tube. 
The arrest depended upon a falling together of the edges of 
the tracheal wound during the inspiratory act. Whether 
this was due to the natural flexibility of the trachea in early 
life, or to the prolonged presence of the foreign body hav- 
ing resulted in general inflammatory softening, the reporter 
does not attempt to decide, though he is inclined to regard 

28 



326 THE DISEASES OF CHILDREN. 

the softening as an important factor, since the first case, not- 
withstanding its youth, was uncomplicated by dyspnoea after 
the removal of the foreign body. The permanent removal 
of the tracheotomy tube is sometimes a matter of great diffi- 
culty, although it can usually be ultimately accomplished 
if enough patience be exercised. The trouble arises both 
from the fact that the granulations arising in healing may 
act like a valve-leaflet during inspiration, and from the irri- 
tability and disorderly action of the glottis muscles so likely 
to follow the operation. 

In both of these cases the operation was performed by 
Professor John Ashhurst, Jr. 

The third case was a girl, aged seven years, also a patient 
at the Children's Hospital. On the night before admission 
she supposed she had swallowed a pin which she was hold- 
ing in her mouth, but was convinced to the contrary by a 
sudden attack of coughing and by pain referred to the upper 
part of the larynx. On examination the only symptoms 
were pain, a sensation of 4< sticking " in the region men- 
tioned, and cough ; by the finger the point of some sharp 
body could be felt beneath the skin a little to the right of 
the pomum adami. After etherization Dr. Wharton made 
an incision a little to the right of the median line of the 
neck, where the point of a pin was seen -imbedded in the 
right ala of the thyroid cartilage, it was seized with forceps, 
drawn down until its head impinged upon the inner surface 
of the cartilage, and its complete removal accomplished by 
a trifling incision. Very little air escaped through the inci- 
sion, there were no unfavorable sequelae and the patient 
made a rapid and complete recovery. 

The reasons for selecting the external rather than the 
internal method of removal were the extreme difficulty of 
controlling the child, and the fear that a delay might be 
followed by some unfavorable change in the position of the 
foreign body.] 



BRONCHITIS AND BRONCHI: 






CHAPTER XXI. 



BRONCHITIS AND BRONCHIECTASIS, 



Bronchitis is :-r.e of the commonest affections of child- 
hood. It is most common as a disease of the large and 
medium-sized tubes, but is very apt to read from :*/. : 
the smaller tubes, and to lead to broncho-pneumonia an 
atelectasis. It is in respect of these d : s e ? ises that its impor- 
tance chiefly lies. It is usually \ iscr ibed tc the effects of chill, 
but, without denying this in any way, I believe its cause to 
be far more often intrinsi : than e::: rinsi :. if I may s : Sf 
There are many children who have an ronchitis, 

mostly of the larger tubes, when tee:/, .-.re ;ust coming 
through the gums ; there are others, usually older children, 
whose irregularities in diet and in the gastro-intest 
secretions are revealed in the same way. The ascaris lum- 
bricoides may provoke similar disturbances, and the symp- 
toms possibly subside on the expulsion of the urns. Su ch 
ts are probably of neurotic origin, and are examples :f 
reflex nervous disturbance, the worry at one end of a nerve 
being transmitted to some other station in communication 
with it. Tie:: there are the specific poisons, such as that 
of measles, of pertussis, or of typhoid fever; there are local 
peculiarities of action in the muscle of the bronchial tut 
there are all the conditions of catarrh in the upper passag 
there are the series of tubercular conditions which, in any 

n case, must all be taken into consideration; and 
but not least, there are the chronic cone .n en dent 

upon atelectasis, which are ever ready to excite 
catarrh. No ill these, there are many ot 






328 THE DISEASES OF CHILDREN. 

causes of which we know even less ; exposure of the skin 
to chills will interfere with its action, will disturb the balance 
of the circulation, and tend to throw undue stress upon all 
the viscera, the lungs amongst them. Atmospheric disturb- 
ances, electrical and other, abnormal constituents of the 
particulate dust, must also be of importance ; but it is of 
very little use discussing these things at length, for at best 
it could be but as the blind man offering to lead his fellow. 
In dealing with bronchitis, however, and all such things as 
are supposed to be determined by chill, I would have the 
student interpret this in the widest sense, and think out 
carefully for himself how much or how little it may mean. 

Symptoms. — Acute bronchitis, as it is seen in any of these 
cases, is a pretty definite disease. Its onset is usually sud- 
den, attended with hig.h fever (102 or 103 ), rapid labored 
respiration, dilating alae nasi, and usually with a good deal 
of perspiration. The tongue is thickly furred. There is a 
frequent, short, dry, and subsequently a moist, cough. On 
examining such a case, the chest will be rising very rapidly, 
the sternum plunging forwards, probably the lower ribs at the 
same time becoming retracted inwards, and the diaphragm 
moving forcibly downwards, so as to round the abdomen 
into a ball-like shape at the end of inspiration. The more 
the impediment to the entrance of air into the lungs, the 
more will these features be noticed, and the severity of the 
case may in great measure, therefore, be judged in this way. 
In the worst cases the features are livid and the child very 
restless. On percussion, nothing will be made out with 
certainty, and on auscultation there will be bubbling and 
squeaking all over the chest. At the apices the inspiration 
will be harsh and the expiratory murmur long and snoring, 
while the sounds at the bases are moister, and will be trans- 
mitted more strongly to the -ear, should the disease be asso- 
ciated with broncho-pneumonia. 



BRONCHITIS AND BRONCHIECTASIS. 



329 



As a rule, there is no expectoration, and the cough need 
not be a prominent feature. Sometimes it is frequent and 
distressing, and occasionally it comes on in paroxysms, and 
is attended with the passage into the mouth of muco-purulent 
material, not unlike that in pertussis, which should be re- 
moved by a pocket-handkerchief. At other times, although 
the respiration is very rapid, the cough indicates by its 
harshness that the upper parts of the air-passages are mostly 
affected. 

The disease is one of variable duration — seven or eight 
days may be given as perhaps an average. It is usually 
accompanied by anorexia and thirst, whilst the urine is 
stated by Meigs and Pepper to be frequently temporarily 
albuminous. 

But a large number of children who apply for treatment 
in the out-patient rooms of hospitals have a much milder 
attack than this. They are out of sorts, often rickety, and 
have cough with some slight pyrexia, and on auscultation 
some coarse and fine rales are heard in various parts of the 
chest. 

An equally important group of cases is related to the acute 
bronchitis which follows a persistent dilatation of the tubes 
and atelectasis. In these cases, again, the respiration is very 
rapid, shallow, and often labored; the child is restless, blue, 
and bathed in perspiration, and there is a frequent short," 
moist cough. The temperature generally rises to 102 or 
so. The tongue is thickly furred. The auscultatory signs 
are much like those in the former case, but, supervening as 
the disease does upon collapse and bronchiectasis, there may 
be very little air entering the bases of the lungs, more or less 
dulness, and even signs of considerable consolidation. 

Diagnosis, — Two difficulties may be noticed — one as re- 
gards the general symptoms. There are many children 
during the period of the first dentition who suffer from an 



330 THE DISEASES OF CHILDREN. 

acute febrile condition of sudden onset, and in which the 
respiration quickens in proportion to the fever. It is not 
difficult to mistake the appearances in such a case for those 
of bronchitis, but the auscultatory phenomena are not those 
of bronchitis, and after two or three days — perhaps before, 
perhaps on the eruption of a tooth, perhaps on the adminis- 
tration of some aperient or diaphoretic — down drops the 
temperature, as suddenly as it rose, and the child is practi- 
cally well. 

A more serious difficulty is to determine whether there 
is any actual consolidation of the lung. Very careful aus- 
cultation of the lung, inch by inch, will be required to de- 
termine the point, and a careful weighing of the character 
of the mucous rales that are to be heard. And when the 
acute disease supervenes upon a chronic condition, the 
amount of dulness towards the bases from the pre-existing 
collapse makes the question a difficult one to decide. Bron- 
chitis, collapse, and broncho-pneumonia, are, however, so 
frequently associated that in one sense the importance of the 
question is minimized, and it is often decided rather upon 
the general symptoms than upon the physical signs, which 
may be hard to gauge with accuracy; in another sense it is 
of the more importance, determining, as the existence of 
pneumonia often will, a fatal issue. Under special circum- 
stances also the diagnosis becomes difficult. For instance, 
at the termination of whooping-cough, the wasted condition 
of the child, and the excess of pulmonary impediment, may 
easily simulate phthisis. I have before alluded to the bron- 
chitis of typhoid fever being occasionally so severe as to 
mask the essential disease. 

Prognosis. — This must depend upon the general symp- 
toms rather than upon the physical signs. Where the respi- 
ration is very rapid and labored, the dyspnoea increasing, 
the child blue and exhausted though restless, cool, and 






BRONCHITIS AND BRONCHIECTASIS. 



331 



clammy, somnolent, and taking food badly, the prognosis 
must be grave. If, too, there be much inspiratory retrac- 
tion of the sides of the chest, or the sharp rales of broncho- 
pneumonia in addition, or if the child be very drowsy, or the 
Cheney-Stokes* type of respiration become at all pronounced, 
there is of necessity an added risk. All the same, the opinion 
should be a cautious one ; for, with careful treatment, the 
worst-looking cases may slowly pull round. 

Treatment. — The child is placed in bed, and in a tent 
with a steam-kettle in the neighborhood to moisten the air. 
A little carbolic acid may be put into the vapor — one in 
eighty will be sufficient. A jacket of cotton-wool should 
be made to lightly envelop the chest. The food should be 
easily assimilable, not necessarily milk or beef-tea only, but 
egg, custard, blanc-mange, jelly, sponge-cake, etc. 

For medicinal administration, some expectorant should 
be given — bicarbonate of potassium, nitrate of potassium, 
syrup of squills, and ipecacuanha are all good. They may 
be given singly or combined, and some syrup of Tolu and 
aquae anethi added to make them palatable. If the prostra- 
tion be great, carbonate of ammonium and ipecacuanha wine 
make a useful combination as the secretion from the bron- 
chial tubes becomes more fluid. An emetic may sometimes 
be given to clear the tubes — a teaspoonful of the vin. ipecac. 
or five grains of the powdered root. Subsequently, a little 
syrup of squills, with the lacto-phosphate of lime and iron, 
may be given. The bowels should be kept gently open by 
aperients, as may be necessary; and, in the later stages, 
quinine may be useful, as well as cod-liver oil and other 
general tonics and restoratives. 

Chronic Bronchitis is sometimes a result of an acute at- 
tack, or several such; it sometimes remains after whooping- 
cough; sometimes it is the sequel of atelectasis ; and some- 
times all we can say is that it exists, but how it came about 



332 THE DISEASES OF CHILDREN. 

there is no evidence to show. Under any or all of these 
conditions the child is more or less blue, with short breath 
and a deep chest, flattened from side to side, with a promi- 
nent sternum ; the finger-ends are bulbous; it moves about 
in a lethargic way, as if life were an exertion, and has a 
frequent short moist cough. Sometimes the chest is full of 
moist rales, both large and small; sometimes there is little 
to be heard, except that the inspiratory murmur is clipped 
or shortened, and somewhat labored. A long expiratory 
murmur is not, I think, a very marked feature of bronchitis 
in childhood. In the more advanced cases, the cyanosis 
and clubbing of the fingers may be extreme; the inspiratory 
recession of the lower and lateral parts of the thorax is very 
great. There may be evidence of distension of the right side 
of the heart, in the fulness of the veins and epigastric pul- 
sation; but the lungs, being emphysematous in front, do not 
often allow of the detection of any increase of the praecordial 
dulness on the right side. The copious expectoration of 
pus, and sometimes of offensive pus, has been said to occur 
in older children, and to be indicative of dilatation of the 
bronchial tubes, but this must, I think, be of very excep- 
tional occurrence. 

Morbid Anatomy. — Such cases as these are apt, in the 
end, to be fatal by the repetition of the attacks. Each attack 
leaves the lung in a worse state than it was before, and the 
child's condition is one of gradual deterioration. The ap- 
pearances usually found are patches of solid collapsed lung 
in various parts, more particularly towards the base and 
round the lateral region of the thorax ; and the bronchial 
tubes are considerably dilated and full of thick pus. Thicken- 
ing, roughening, and ulceration of the mucous membrane of 
the tubes have been described, but I think such conditions 
are rare. It seems to me to be much more remarkable how 
seldom there are any marked changes in the tubes commen- 



BRONCHITIS AND BRONCHIECTASIS. 



333 



surate with the extent of disease, if dilatation be excepted. 
The tubes are generally dark colored and congested, but not 
swollen or roughened in any way. The dilatation of the 
tubes is seldom other than a uniform one; saccular dilata- 
tions are quite uncommon. The lungs are usually moder- 
ately emphysematous along their anterior borders, at their 
edges elsewhere, and at their apices. In addition to the 
morbid appearances in the lungs, there will be found, more 
or less, those associated conditions of the viscera dependent 
upon the obstruction to the pulmonary circulation — viz., a 
large and probably dilated right heart, a nutmeg liver, and 
congested kidneys. 

Prognosis. — These cases usually go on for a long time. 
Their history is for the most part one of chronic ailment, 
with intercurrent attacks of more acute inflammation, in all 
of which they are very ill, and the issue for the time doubt- 
ful. In one of these attacks they may ultimately die. Such 
cases, however, repay care; for again and again they may 
pull through a serious attack, when apparently in an almost 
hopeless state, and I think one is justified in saying that, in 
many cases, something amounting to repair goes on. In 
young children, it is not incorrect to say that they may 
" grow out of it," for they greatly improve as their ribs 
stiffen. But there are other risks — one is of acute pleurisy, 
another of some ulceration of the lung; both these come 
about by the medium of dilated bronchial tubes. The secre- 
tions collect in them, near the surface of the lung or else- 
where, and, decomposing, set up an acute pleurisy, or some 
destructive broncho-pneumonia. 

Treatment. — This is much the same as for other more 
acute cases. They require always to be kept very warm, to 
be warmly clad, exposed as little as possible to the vicissi- 
tudes of climate, and in any acute attack to be kept in bed. 
Alkalies are useful in promoting expectoration, and some 



334 THE DISEASES OF CHILDREN. 

stimulating expectorant may be added to them. Four or five 
drops of sal volatile with a similar quantity of tincture of 
senega, and some bicarbonate of potassium with some syrup 
of Tolu, make an effective mixture at this time. In the later 
stage, when the expectoration is very copious, alum or gallic 
acid may be given. (F. 25, 36, 41.) Besides internal reme- 
dies, daily friction of the back and sides of the chest by soap 
liniment or simple oil seems sometimes to be of service. 
Later still, these cases usually do well upon mild ferrugi- 
nous tonics. Quinine is also advised at this stage, and there 
can be no objection to its administration in half-grain doses 
three times a day. Quinine is best administered in milk, 
but it may be given with syrup or liquorice, and the recom- 
mendation of Meigs and Pepper, to combine it with a little 
curacoa, is a good suggestion, if there be much repugnance 
to it in other ways. Maltine, cod-liver oil, and such like 
remedies, are also often valuable in improving the general 
health of the child. 

Bronchiectasis. — It may be quite an open question 
whether this is to be considered a distinct disease; my rea- 
son for devoting a separate paragraph to its consideration 
is that it has been taught that there are special symptoms 
disclosing its existence, and one would like, therefore, to in- 
dicate what these are. It would appear that it occurs mostly 
between five and nine years, twelve out of twenty cases being 
within that period. Bad pertussis frequently antedates it. 
From notes of twenty cases in which I supposed this condi- 
tion to be present, there is expectoration, sometimes vomit- 
ing of large quantities of thick, purulent, possibly offensive 
pus. The chest is usually deformed, either pointed in front 
or flattened on one or other side, and there is often an ir- 
regularly distributed dulness perhaps at one apex, and on 
one side, or in patches in different parts of the lungs. The 
physical signs are those of bronchitis of the larger tubes, 



BRONCHITIS AND BRONCHIECTASIS. 335 

nally some sharp rales in various parts of the 
s. It is but seldom that anything suggestive of cavita- 
tion is heard, probably because these dilatations usually 
occur in the substance of the lung and are surrounded by 

cular pulmonary tissue. There is usually more or 
cyanosis, clubbing of the fingers, and a generally labored 
breathing and indolent habit. With the exception, perhaps, 
of copious expectoration of pus, these symptoms indicate not 
so much dilatation of the tubes as that condition of lung to 
which the dilated tubes owe their existence, and this may be 
sometimes an old chronic bronchitis, sometimes extensive 
collapse, sometimes some old fibroid changes on one side or 
the other. It has been supposed by some that there is a 
special significance in fetor of the expectoration. I am in- 
clined to doubt this. I believe it to be much more near the 
truth that when fetor of the bronchial discharges exists there 
is generally some destructive disease of the lung or ulcera- 
tion of the bronchial tubes. 

Morbid Anatomy. — The commonest form of dilatation is 
a uniform one. A section of the lung shows the tubes 
unduly large, and the scissors run along them with ease to 
the surface of the pleura. They generally contain more or 
thick pus. Their lining membrane is red or livid; 
thickening is not a noticeable feature. This state of things 
is very usually associated with emphysema at the anterior 
and basal edges of the lungs, and also with some collapse. 
Saccular dilatation is rare. The tubes are in these cases 
thin rather than thick, and form sections of cysts on the cut 
surface of the lung. These occur in the substance of the 
lung rather than near the surface, and are often surrounded 
by a small nodule of consolidated lung. An exaggerated 
form of this disease is met with occasionally in which these 
cysts are very numerous and very large, the sections of the 
lower parts of the lobes being thickly studded with them. 



336 THE DISEASES OF CHILDREN. 

The lung-tissue intervening is at most only emphysematous 
and the pleura is usually adherent. Very little is known 
about this condition ; it has seemed to me that it might 
possibly be of congenital origin, the physical signs have 
been so little pronounced, and the evidences of the disease 
so obscure. There is yet a third condition, in which usu- 
ally one or other base of the lung is contracted and con- 
densed, and the tubes are more or less widely dilated. The 
dilatation in these cases is neither uniform as in the condi- 
tion already described, nor saccular as in the other, yet on 
slitting them up along their course there is a good deal of 
irregular dilatation, and the cavities so exposed are puckered 
by the existence of transverse rugae. These also are found 
chiefly in the substance of the lung. This state of things 
is usually dependent upon some old pleurisy or chronic 
pneumonia. 

The prognosis and treatment are much the same as for 
chronic bronchitis. These children require to be kept in as 
pure an air as possible, in as equable a temperature as pos- 
sible, and, save when any acute attack threatens, in a dry 
atmosphere. If there is much accumulation of mucus in the 
tubes, an occasional emetic will relieve them, and for the 
rest they require tonics and fattening. 



PNEUMONIA. 



337 



CHAPTER XXII. 



PNEUMONIA. 



Pneumonia. — It is usual to describe this disease as lobar 
or fibrinous* ; and lobular or catarrhal and broncho- 
pneumonic ; but, time-honored though such a description 
may be, it is liable to mislead the student. An acute 
pneumonia — which has the clinical features of the croupous 
pneumonia of adult life — is not uncommon in childhood ; 
sudden onset; high fever; crisis; and sudden fall of tem- 
perature. But the difficulty is that the larger proportion of 
cases of pneumonia are not quite this, and yet they are 
lobar pneumonias as regards their physical signs. They run 
a less typical course, and whilst partaking in some respects 
of the nature of the one form of disease, in others they are 
more like the catarrhal form. Nor is the difficulty lessened 
by appealing to the facts of morbid anatomy ; for acute 
pneumonia, be it clinically lobar or lobular, seems to me to 
present such appearances in every case, as make any dis- 
tinction between the two forms, save one of degree, a very 
difficult matter. I am not familiar with the red and grey 
hepatization which are described as occurring in childhood 
as in adults, when the disease is of the fibrinous form ; but 
the clinical data are sufficiently precise to forbid all doubt 
that such a disease as acute fibrinous pneumonia has a very 
real existence. The student must bear in mind, however, 
that the labor pneumonia of children is more often catarrhal 
than fibrinous, and that, therefore, the disease here de- 
scribed as such has a wider range than that usually given 

* Croupous. — Ed. 



338 THE DISEASES OF CHILDREN. 

to it. The remarks which follow are, indeed, chiefly based 
upon the commoner form of the disease, and the morbid 
anatomy is described from the fatal cases resulting from this 
form. Possibly the fibrinous pneumonia is but seldom fatal. 
This catarrhal origin may explain the fact that the lobar 
pneumonia of children so often begins at the root of the 
lung, and spreads upwards or downwards; here also may 
possibly be found an explanation for another fact — viz., that 
pneumonia at the apex of the lung is, as is usually supposed, 
a commoner disease in children than in adults. The pneu- 
monia of adult life commences as a parenchymatous change 
at the base of the lung, and extends up the posterior part, 
reaching the apex and front last of all. But if the root be 
the more frequent seat of onset, it is clear that the apex and 
base are equally exposed to the risk of extension, and an 
apex pneumonia might be expected to be more common. I 
have analyzed all my cases with a view to giving some in- 
formation upon some of these points, and one or two inter- 
esting facts are arrived at by this means. 

Out of 165 cases, forty-five were lobular pneumonia, 
with a mortality of twenty. Such a small number of cases 
of lobular pneumonia is, in part, accounted for by the fact 
that — being more common — less careful notes have been 
taken of such cases, and, in part, by many cases being in- 
cluded with those of bronchitis. One hundred and twenty 
were lobar ; fifty-one of the left base, with fourteen deaths ; 
seventeen of the left apex, with two deaths ; thirty-four of 
the right base, with two deaths ; eighteen of the right apex, 
with seven deaths. Apical pneumonia appears, then, to 
occur twice to five cases where the disease is basal ; whilst 
disease at the right apex is the most fatal, and that at the left 
base next. Henoch gives seventy-four cases, two in which 
the disease attacked the entire right lung ; two both lower 
lobes ; twenty-one the right upper lobe ; eighteen the right 



PNEUMONIA. 339 

lower lobe ; four the left upper lobe ; and twenty-seven the 
left lower lobe. As regards the mortality, my figures are, 
however, open to the exception that four-fifths were from 
out-patients. The mortality is, therefore, probably higher 
than it need be. I have made no mention of double pneu- 
monia, because in all these cases it was essentially one- 
sided ; but in several cases patches here and there were 
discovered from time to time in the course of the disease^ 
which make me agree with the opinion of Dr. West that 
double pneumonias are not uncommon. There is some 
difficulty in being sure of the fact in the absence of an 
autopsy, for the sounds of consolidation are transmitted 
from side to side, particularly about the root, with great 
readiness ; and it is also quite common in the auscultation 
of the lungs of children suffering from pneumonia to meet 
with evidences of consolidation at one visit which have 
gone at the next, or within a short time, and which must, I 
think, indicate a still more ready interchange of collapse 
and expansion than has, possibly, hitherto been appreciated, 
notwithstanding all that has been written on the subject. 
For this reason I hesitate to say that the disease attacks 
one side more frequently than the other. These figures 
tell rather in favor of a small left-sided preponderance ; but 
other authors have thought it otherwise, and I suspect, 
therefore, that there is not much difference in this respect 
over a large range of cases. 

Sex, — Of the above cases, seventy-seven were girls and 
fifty boys. This is not in accord with general experience, 
but, as is well known, different sets of statistics are liable to 
give contradictory results. It appears pretty certain that, 
taking a large number of cases, pneumonia occurs more 
often in boys than in girls; but I give my own numbers for 
what they are worth. Nor am I in more than partial agree- 
ment with others as regards the age of patients suffering 



340 THE DISEASES OF CHILDREN. 

from lobar pneumonia. No doubt nearly all cases occur under 
five years (eighty-two out of ninety-three) ; fifty-one cases 
were under two, and thirty-one between two and five. Such 
discrepancies as exist may be explained in great measure, 
if instead of taking an anatomical basis of classification, we 
take the clinical one — the younger the child, the more is 
the disease associated with bronchitic symptoms, in which 
the disease may often originate ; the older the child, the 
more likely is the disease to have a sudden onset, perhaps 
by convulsions, and all the signs of bronchitis to be absent. 
Morbid Anatomy. — The lobar pneumonia of childhood, 
as seen in the post-mortem room, differs from that of the 
adult in wanting the distension or solidity that is found in 
adults, and also the granular or dull rough surface which is 
so characteristic. As in adult life, it is often associated with 
pleurisy. The child's lung is smaller, denser, darker colored 
than natural, of a bluish, violet, or leaden tint, and the cut 
surface is comparatively smooth. It is often very finely 
sanded, and may look vesicular, or almost gelatinous. 
When the disease has progressed some few days, the sur- 
face thus described is generally studded over with circinate 
patches of granular yellow or yellow-red color. These are 
the terminal bronchi with the pulmonary vesicles around 
them full of inflammatory material, on its way towards grey 
or fatty changes. The intervening parts are solid, dark- 
colored, and hardly granular. They are more solid than in 
the solidity of collapse; less so, at any rate less bulky, than 
in the lung of acute croupous pneumonia. This is the con- 
dition which has no doubt given rise to so much questioning 
and discussion— some calling it collapse, others pneumonia. 
I shall, perhaps, not better matters much. by saying that it 
is neither one nor the other ; but, none the less, such a state- 
ment is strictly true. In childhood the respiratory move- 
ments and the circulatory conditions are not exactly the 



PNEUMONIA. 34I 

same as in adults. As I have before said, if we listen over 
a child's chest we frequently hear that now one part, now 
another, is moving more fully, depending upon a less uni- 
formly equable expansion of the chest; and with dissimilar 
conditions come dissimilar morbid changes. The common 
form of pneumonia is due to a complex series of changes : in 
part, and no doubt a prominent part, due to collapse ; in part 
to catarrhal changes in the tubes and air-vesicles ; in part to 
blood-stasis simply ; in part to swelling and thickening of the 
connective tissues surrounding the smaller bronchi and the 
septa of the lung. The last-mentioned conditions are very 
prominent features of the pneumonia of childhood, while the 
exudation of fibrin is of very limited occurrence. I am by no 
means sure also as to whether some process of adhesion may 
not go on in the walls of the inflamed air-vesicles. If not, 
they become much thickened and fibroid-looking, and in parts 
of such lungs the vesicular structure may be quite obliterated, 
and the observer appear to be looking at an unbroken field of 
fibro-nucleated tissue. It is most difficult in some cases to 
say what is the exact nature of the changes histologically ; 
but this I know, that appearances quite unlike those of the 
acute pneumonia of adult life present themselves. Neither 
are such changes comparable to those met with after com- 
pression by fluid. The peculiarities in the anatomical ap- 
pearances have been described by several writers. Rilliet 
and Barthez ascribe them, in part, to the interstitial exuda- 
tion to which I have alluded; others to a lessened amount 
of fibrinous exudation. I should suppose that both these 
departures from the adult type are of importance. The 
absence of fibrinous exudation may, however, be particularly 
insisted upon, because, if such be the case, it will be apparent 

khow difficult it must sometimes be to distinguish between 
pneumonia and collapse of the lung. 
The nature of the later stages of a lobar pneumonia in 
29 



342 THE DISEASES OF CHILDREN. 

children is also by no means free from obscurity; but from 
what is seen in lobular pneumonia and from an occasional 
case of fibrinous pneumonia, it has been more surmised than 
proved that there is some such change as that denominated 
grey hepatization, and through which resolution comes 
about. Nevertheless, remember that children hardly expec- 
torate at all ; nor are they in many cases troubled much 
with mucus in the tubes. The breathing has been said to 
be easy in these cases, in contradistinction to the labor of 
bronchitis ; therefore, probably in many cases some process 
of liquefaction and absorption occurs; in fact, that which is 
occasional in the adult is common in childhood. In the 
more chronic cases no doubt there is a tendency to the 
formation of patches of cheesy pneumonia, or to a condi- 
tion, presently to be described, in which a considerable 
part of one lobe may become converted into a solid cheesy 
mass. 

The morbid appearances of lobular pneumonia differ in 
distribution, but not much otherwise. A section of a lung 
thus diseased shows an uneven surface, from the existence 
of eminences and depressions. According to the stage 
arrived at, so will the eminences be either simply dark- 
colored from congestion, and their relations to the smaller 
bronchi perhaps not very distinct; or else actually solid, 
with a central dilated bronchial tube containing pus. In the 
latter case the eminences will either be of a dark livid color, 
almost translucent near the central bronchus, with no well- 
defined margin, or yellow or fawn-colored from the degen- 
erative changes in the inflammatory products. In this way 
are produced clusters of nodules, the cut section being often 
finely granular; and these may run more or less together, 
solidifying the whole lobe, or part of it, and producing a 
nodular solidification, which gives to the diseased part a 
somewhat peculiar feeling when grasped between the finger 



PNEUMONIA. 343 

and the thumb. Histologically, the smaller bronchi are 
often very much thickened by a crowded cell-growth in their 
submucous tissues, and the air-vesicles around such affected 
tubes are full of inflammatory products , but accompanying 
these changes, and in proportion to the diffusion of the 
centres of inflammation, and to the duration of the disease, 
is a very similar state of things to that described under the 
head of lobar pneumonia. The smaller bronchi are often 
dilated. 

Hillier describes lobular pneumonia as disseminated or 
generalized, and when the latter, closely resembling the lobar 
form. He also alludes to a description by Ziemssen of 
chronic cases of this variety taking origin in collapsed parts, 
a change which sometimes involves a whole lobe. The ap- 
pearances of this disease seem to be identical with what has 
been here described as the common form of lobar pneumonia 
in children. 

Causes. — Little is known of the cause of fibrinous pneu- 
monia. It generally appears to be spontaneous, but its 
etiology is involved in as much doubt as is the like disease 
in adults. Some consider it due to exposure ; others to 
atmospheric disturbances ; others to septic conditions, etc. 
All, however, seem to agree that a child attacked once may 
be so several times. It is more common in the strong than 
in the weakly, and in the winter and spring than in the sum- 
mer months. 

Of that form of lobar pneumonia intermediate between the 
fibrinous form and the catarrhal or lobular pneumonia — 
which last I have more particularly described because of its 
more frequent occurrence — it is almost impossible to say 
anything for certain, save that it more often follows measles 
and other acute specific diseases, and is the termination of 
not a few cases of atelectasis and chronic bronchitis. 



344 THE DISEASES OF CHILDREN. 

Acute lobular pneumonia is usually secondary to measles, 
pertussis, or some chronic bronchitis. 

Symptoms. — We must now more sharply distinguish 
between the fibrinous and the catarrhal forms of the disease. 
Acute fibrinous pneumonia is, as in adults, a disease of sud- 
den onset. There may be rigors or convulsions, headache, 
vomiting, muscular pain, pain in the side, and high fever 
(103 to 105 ). It is a disease of a few days only, ending 
in a crisis, but it may last any time, from three or four days 
to seven, eight, or nine. It is usually associated with pleu- 
risy, and this to some extent masks the disease, and gives 
its symptoms a special color. The pain may be very acute 
for a day or two, and the child's features, particularly if it be 
very young, may become pinched. The cough is stifled, or 
with it there comes a cry, or sometimes a shriek. As be- 
tween bronchitis and pneumonia, Meigs and Pepper, I think, 
allude to a distinction which is not unserviceable, that the 
child with pneumonia breathes easily, though very rapidly, 
whilst the bronchitic gets his breath with labor. Of course, 
with much pleurisy this is modified, and the child with acute 
pleuro-pneumonia sits up in bed giving vent by turns to 
short grunts and a harsh, dry, short cough. The child's 
face is flushed, its skin hot and dry, the lips, perhaps, cov- 
ered with herpes. Some cases are ushered in with violent 
cerebral symptoms, and have been described by Rilliet and 
Barthez as a distinct variety, " cerebral pneumonia." In fre- 
quently recurring convulsions, and in headache, vomiting, 
delirium, and drowsiness, these cases may resemble, and be 
mistaken for, meningitis. Moreover, they are usually severe, 
and Hillier and others consider them more likely to occur 
with pneumonia at the apex than elsewhere, and this has 
certainly been our experience at the Evelina Hospital. It 
may be worth w T hile to point out, in reference to this obser- 
vation, that some have thought that apex pneumonia in adult 



PNEUMONIA. 



345 



life is not only severe, but liable to own a septic origin. Pos- 
sibly, also, the fact that I have already insisted upon, that a 
pneumonia of the apex is often a pneumonia of the root of 
the lung, may also have its meaning in this respect. 

The disproportion between respiration and pulse is usually 
well marked, the former rising to sixty or seventy per minute. 
The alae nasi dilate with inspiration until the severity of the 
disease lessens. The temperature generally falls suddenly 
from 103 or 104 to normal, or below it, and may rise again 
slightly at night for a fortnight before it finally rights itself; 
and here I may mention, with regard to this, that Dr. Newn- 
ham, our present resident medical officer at the Evelina Hos- 
pital, tells me that it has been no uncommon thing for him 
to receive a summons from a nurse to come at once to such 
a case, because the temperature has fallen, quite suddenly, 
perhaps from 103 or 104 to below 98 , and the nurse has 
feared something was going wrong with the child. If, after 
the crisis, the temperature should again rise, particularly at 
night, the formation of fluid, and perhaps pus, in the pleura, 
or some fresh mischief in the lung, may be suspected. These 
acute forms of inflammation of the lung are not at all un- 
commonly succeeded by empyema. Associated with the 
crisis there is usually copious perspiration. Recovery after 
the crisis is often astonishingly rapid ; the solidification, as 
judged by the physical signs, will sometimes disappear within 
a day or two, nor is it necessarily accompanied by much evi- 
dence of softening in the way of mucous rales. Steiner makes 
a note that in several cases he has found complete absorption 
to go on without the occurrence of any moist rales. The 
tongue is naturally often thickly furred ; vomiting maybe 
obstinate for the first day or two ; the bowels are confined ; 
the urine scanty, and its chlorides absent. 

Physical Signs. — In a typical case there will be more or 
less rapid onset of tubular breathing, associated with dulness 



34-6 THE DISEASES OF CHILDREN. 

on percussion, the latter often deepening as the case pro- 
gresses, by reason of its frequent association with pleuritic 
exudation, either of lymph or fluid. But it is well to 
remember that bronchial breathing is sometimes slow in 
appearance, and this, I think, in cases in which one would 
expect it quickly — viz., those which from general symptoms 
seem very acute. Hillier notes this delay in the appear- 
ance of bronchial breathing in cases of apex pneumonia. 
But it is not only the delay of the appearance of a morbid 
quality of respiration; the vesicular murmur is sometimes 
absent altogether, and the lung appears to be almost silent — 
so much so, indeed, that in some cases it seems possible the 
tubes may become filled with fibrinous coagula, which might 
bar the entrance of air into the solidified part. I have lately 
had a child under my care who illustrates this and other 
points very well. He is a little Jewish boy of six, and was 
admitted with excessively acute symptoms and a temperature 
of 104 . I saw him first on the fourth day of his illness, and 
the respiration was so nearly absent over the apex and in 
the axilla of the left side that I suspected fluid. A needle 
was passed into the chest in the axillary region, but nothing 
came out, and at my next visit well marked tubular breathing 
had developed all over the apex of the lung, back and front. 
The symptoms continued severe, although he gradually 
improved, till the eighth day, when, between nine and twelve 
midday, the temperature fell from ioo° to 97 , but it rose 
again at night to 10 1°, and after that, for two or three days, 
rose even to 102 at night. A careful examination had 
revealed a similar absence of respiration again over the front 
part of the lung; but now, in addition, the heart-sounds 
were distinctly louder to the right of the sternum than in 
the proper position, and, although the praecordial dulness 
did not appear to be altered, the pulsations were decidedly 
most marked behind the sternum. An exploring needle 



PNEUMONIA. 347 

was again passed into the chest in the axilla, in the same 
spot as before, and some pus was withdrawn. This was 
evacuated by incision on the fourteenth day of his attack, 
the chest was drained for a few days, and he rapidly got 
well. 

The percussion is often misleading to students. If there 
be pneumonia at the apex, it is usually absolutely dull over 
the disease ; but when there is disease at the base or up the 
back, quite commonly there is a high-pitched tympanitic 
note in front on the same side. It is the so-called Skoda's 
tympanitic resonance. It is best heard in pleuritic effusion, 
but is by no means absent in cases of consolidation. A 
good deal of information is also conveyed to the practiced 
finger by the want of elasticity of the chest-wall, which co- 
exists, it may be, with pneumonic consolidation or with 
pleuritic effusion. A cracked-pot sound may also often be 
elicited under like conditions, only it is not worth while to 
thump the poor child to obtain it, as it conveys no additional 
information. 

I have occasionally heard a peculiarly harsh inspiration 
in the earliest stage of pneumonia ; but the respiration is 
often faintly bronchial rather than harsh. The fine dry 
crepitation is often absent. When the consolidation begins 
centrally, it may be some days before much is heard at the 
surface of the lung. Careful examination should then be 
made daily over the root of the lung. It is but seldom 
that bronchial breathing, when it exists, cannot be detected 
there. 

In the catarrhal form of lobar pneumonia there is often 
some previous history of ill-health — the child is rachitic, its 
chest deformed, or it has frequently suffered from colds and 
coughs, or it has lately had measles, whooping-cough, or 
some other exhausting ailment. The symptoms are acute 
enough ; nevertheless, there is hardly perhaps that painful 



34^ THE DISEASES OF CHILDREN. 

severity about them which may be seen in the fibrinous 
cases. The temperature does not average so high a range, 
the pain is less, the skin more moist. In place of a flushed 
cheek there may be lividity, and there will be more bron- 
chitis. The course of the disease is very variable, but, as a 
rule, it ends in no definite crisis. The temperature falls 
gradually, and it has a more prolonged course, — any time, 
in fact, from one w T eek to six or eight, although here also 
with careful treatment it will sometimes clear up with great 
rapidity. It is not uncommon thus to meet with these cases 
in our ward devoted to whooping-cough, and to find the 
evidences of consolidation all disappear within a day or 
two, and the same applies to the disseminated form of 
broncho-pneumonia. It must also be said that it is in 
whooping-cough that broncho-pneumonia finds its most 
lingering cases. 

Complications. — Acute pleurisy and acute pericarditis 
are met with ; the former commonly, the latter rarely. 

Diagnosis. — Anything which produces consolidation of 
the lung may resemble a pneumonia in some respects. I 
have noted as specially worth caution, that fluid at the base 
of the lung, by leading to pressure upon the lung, will fre- 
quently give rise to bronchial breathing at the apex under 
the clavicle, and so to a suspicion of the existence of pneu- 
monia. This is more liable to occur in chronic cases of 
effusion, and therefore in those where the elevation of tem- 
perature is unlike that in pneumonia. Perhaps, however, 
the best method of distinction is to take this axiom, that 
whenever there is evidence of fluid at the base of the lung 
we must distrust any indication there may be of consolida- 
tion at the apex. 

Fluid collected in the front part of the pleura may simu- 
late pneumonia. I have seen this twice or three times, and 
have cleared up the doubt on more than one occasion by the 



PNEUMONIA. 349 

use of the exploring syringe in the second or third inter- 
costal space. 

In pleurisy the temperature is not usually very high ; 
vocal resonance is diminished ; there is often a peculiarly 
damped tubular breathing of sniffling character, and the vis- 
cera may be displaced. 

Acute caseous consolidation may also have to be distin- 
guished. The disease is less rapid, the temperature less 
high and more oscillating, and the previous history, family 
history, and general conditions must all be taken into ac- 
count. 

Meningitis may be discerned by its lower and oscillating 
temperature; by the irregularity of pulse and respiration, 
and by the absence of any quickening of the latter, of dilata- 
tion of the alae nasi, or of physical signs. 

In atelectasis, although the signs of consolidation may be 
considerable, the fever is little or none ; and there is in addi- 
tion a lividity with labor of respiration quite uncommon in 
pneumonia. 

Acute tuberculosis gives signs, if any, of acute bronchitis, 
not of pneumonia; although one case has occurred to me in 
which what during life appeared to be an apical pneumonia, 
proved at the autopsy to be a case of acute tuberculosis, 
with much solidification of the lung. 

Prognosis. — Acute fibrinous pneumonia is rarely fatal. 
But if we take all cases of lobar pneumonia as they occur, 
the mortality is by no means inconsiderable — about one in 
every five, though figures of this kind are not very useful. 
An opinion can only be reliable when based upon a careful 
survey of the condition of the child. 

In acute lobular and disseminated pneumonia the outlook 
will be bad, according as it occurs in rachitic or young chil- 
dren (under twelve months), or is associated with much 
lividity. Convulsions are usually followed by death. 

30 



::: TI-II ziszasz-s :? ihiizj.z::. 

Results. — If we except caseous bronchial glands and 
tuberculosis, which are not uncommon, there a~ suits 

of an acute pneumonia. I have once seen a red, indurated 
condition of the lower lobe as the result of some chronic 
pneumonic process, after acute pneumonia, probably from 
in; -_:r.\ The ?.rre::ei !:be sr-rrierirr.rs : e: ; :::: r.::-.zztz i : r. 
into a small fibrous mass of grey or reddish color, with thick 
septa throughout it, and the bronchial tubes widely dilated. 
The pleura is generally thick in these cases, and it is a ques- 
tion how for the disease may not have originated in pleurisy 
rather than pneumonia. I have also seen three case 
which there was considerable fetor of breath, so much so as 
to make me suspect some gangrene of the lung, although in 
?.'.'. rr: ivery :: :k c'?.:e. 

Treatment. — In acute pneumonia the child should be 
placed in a warm bed in a well-ventilated room ; it is to be 
warmly clad in flannel, and the chest enveloped in either 
hot fomentations of spongio-piline or poultices. If it be 
considered advisable to apply counter-irritants, this is best 
done not by putting mustard in poultices, but by app 
a mustard-leaf to the part for as long be requ 

It should be fed on milk and beef-tea, and egg and farina- 
ceous diet may be added. Internally some simple saline, 
such as nitrate or citrate of potassium, may be given, and if 
there be much pleuritic pain, a dose of Dover's powder should 
be given at once. A child of six or eigh: :ay have 

two and a half or three grains of I In 

acute cases I sometimes give aconite tincture r a drop 
every hour for a few hour- is useful in promoting per- 

spiration, and generally in quieting the ^p- 

toms. If notwithstanding these measures the temperature 
remains very high, and the child seems to be getting worse, 
then cold pa: oe resorted to, or a bath, warm, tepid, 

or cold. Of late e v.orable results have accrued 



PNEUMONIA. 35I 

from tepid and cold baths, but they will not probably be 
of use in the pneumonia of children, as these cases, if they 
do not speedily get well, become bronchitic, or pus forms 
in the pleura, etc., so that they are not fit for such a plan of 
treatment. If there be much exhaustion, some brandy should 
be given, half an ounce or an ounce in the course of twenty- 
four hours. When any suspicion of a bronchial origin at- 
taches to the disease, then the atmosphere should be ren- 
dered moist by steam, and some stimulating expectorant 
should be given to the child, such as a few drops of sp. 
ammon. aromat, vin. ipecac, syrup of Tolu,etc. The chest 
should be well covered with moist applications, and a little 
stimulant given. 

Chronic Pneumonia. — There is very little to be said of 
this disease which is not included under other headings — 
for instance, as the result of chronic pleurisy, of rare cases 
of pneumonia, or of atelectasis, one or other lobe becomes 
solidified and ultimately converted into a tough, fibrous, con- 
tracted relic, with its bronchial tubes thickened and dilated. 
Pleurisy, and particularly empyema, is the commonest cause 
of this condition, save and except it occur in the middle lobe 
of the right lung, which appears to undergo some such 
changes as these in consequence of atelectasis, which is so 
common there. Pleuro-pneumonia at the apex is some- 
times followed by chronic apical disease of a destructive and 
tubercular nature. Then, again, there is the cheesy solidi- 
fication of parts of a lobe, which may by some be considered 
as a retrograde change in a pneumonic lung, or a special 
form of chronic pneumonia. There is one other condition 
— viz., the syphilitic pneumonia of infants ; this must, I 
think, be rare, as I have only seen one or two microscopical 
specimens, but it has been described by various writers under 
various names, white hepatization, perhaps, being that which 
best identifies it. Dr. Greenfield has given a careful descrip- 



352 THE DISEASES OF CHILDREN. 

tion of a case which was probably of this nature, and I shall 
quote from this.* The child, a female, aet. twelve months, 
died in the out-patient room of St. Thomas's Hospital. 
There was no distinct evidence of syphilis, but circumstances 
in the family history rendered its existence extremely prob- 
able. The right lung was completely consolidated, in a state 
of full expansion. There was slight recent pleurisy, without 
thickening. The section was yellow T ish-white, the cut sur- 
face smooth and slightly shining, differing markedly from 
the ordinary grey hepafization of acute pneumonia. The 
tissue, being firm and tough, exuded but scanty fluid, and 
minute bands of fibrous tissue ran everywhere through it. 
The microscopical characters of the disease show it to have 
been a condition of extreme and active fibrosis, in which the 
septa and. walls of the air-vesicles were thickened by a fibro- 
nucleated tissue in some parts to complete obliteration of 
the pulmonary structure. 

My friend and colleague, Mr. Symonds, has supplied me 
with sections from another case, undoubtedly syphilitic, for 
the liver showed abundant and remarkable syphilitic hepa- 
titis. The child was three months old. In the recent state, 
the affected lung was in a remarkably solid fleshy condition. 
Microscopically, it shows all the features exactly as de- 
scribed by Dr. Greenfield — the excessive fibro-nucleated 
growth, the extreme vascularity, dilated thin-walled capilla- 
ries running in all directions, and an inextricable jumble of 
fibrous tissue with still remaining air- vesicles, the epithelium 
of which is in many parts intact, in some undergoing pro- 
liferation, which makes it difficult to be sure that the cells 
themselves are not helping forward the process of fibroid 
growth. I would take leave to add, that the histological 
appearances of the earlier stages show also how difficult it 

* " Trans. Path. Soc. Lond.," vol. xxvii., p. 43. 



PNEUMONIA. 



353 



is in many cases to distinguish altogether between the 
changes of atelectasis and those of interstitial pneumonia. 
Looking carefully over this specimen, it is clear that collapse 
of the air-vesicles plays a large part in the process; and, 
comparing it with others of atelectasis, it seems equally 
clear that in them the hyperplastic process, which may go 
by the name of interstitial pneumonia, is by no means absent, 
although in a less pronounced form. 



354 THE DISEASES OF CHILDREN. 



CHAPTER XXIII. 

ATELECTASIS— PHTHISIS. 

Atelectasis or Collapse is that disease in which the lung 
either remains in a foetal condition or returns to a state of 
non-expansion. More or less it is not uncommon at all 
periods of life, but it never reaches such an extreme degree, 
and therefore never puts on quite the same appearances, as 
in infancy. It affects sometimes a whole lobe ; but more 
often patches here and there, the favorite spots being those 
which are liable to be placed at a disadvantage in the inspi- 
ratory expansion, and these are the anterior margins of the 
lungs, the edges of the lower lobes, and the middle lobe of 
the right lung, which last is a particularly frequent seat. 
Some writers distinguish between congenital and acquired 
atelectasis, but there seems little reason for this, since the 
explanation of all forms of collapse is practically the same. 
Anything which prevents the expansion of a lung, either in 
whole or part, will lead to collapse of the parts hampered. 
We see this in adults most strikingly. Supposing that some 
aneurismal or other tumor presses upon, or some syphilitic 
scar obstructs, a bronchus, the lung becomes collapsed. 
Other changes may perhaps go on also which to some ex- 
tent alter the appearance, but the essential condition is one 
of collapse. Take a case of chronic bronchitis. The tubes 
are full of pus, the air can get out and cannot get in again, 
and a lobular collapse is the result. Take, once more, a case 
of extreme weakness, from old age or fever, or whatever 
you will ; the feeble power cannot command a sufficient 
thoracic expansion, and the base of the lung suffers collapse. 



ATELECTASIS — PHTHISIS. 355 

The air becomes gradually less and less ia the unexpanded 
lung till complete airlessness is produced. In infancy, al- 
though, as I say, the appearances of the lung thus collapsed 
may differ from the collapsed lung in adults, the causes at 
work are essentially the same but with this addition, that 
whilst in adults the ribs are hardened, the muscles better 
educated, and the expansion consequently conducted under 
more fixed and regular conditions — in infancy the ribs are 
soft, and the muscles act more unevenly ; in fact, the respi- 
ratory act is in process of being perfected, so that we have 
a respiratory type which is sometimes almost undulatory, 
the different parts of the thorax expanding with comparative 
irregularity. I have already alluded to this in mentioning 
the difficulties of auscultation in childhood, but that which, 
in this way, creates a difficulty becomes also a predisposing 
cause of collapse. There is no need to dwell long upon the 
point, it is easily intelligible, and — given such a state of the 
inspiratory act in children — there is a reason for the frequent 
occurrence sometimes of lobar, sometimes of lobular, col- 
lapse, and for collapse being such a frequent associate of all 
other diseases of the respiratory tract. It is thus that we 
hear of collapse as the result of chronic nasal catarrh, and 
of enlargement of the tonsils ; of its association with bron- 
chitis and broncho-pneumonia; of its occurrence in weakly 
and rachitic children. Further detail is hardly necessary; 
the immediate causes of collapse suggest themselves. For 
instance, a child is born in an excessively feeble state, per- 
haps prematurely ; it wants the strength to take a vigorous 
inspiration, and the lungs, in consequence, remain unex- 
panded. Here is foetal collapse. Later on, perhaps, other 
debilitating causes are at work, and again a gradual expul- 
sion of the air takes place, and then collapse of more or less 
of the lung. At another time, perhaps, it is whooping- 
cough, with a good deal of bronchitis — or some catarrhal 



35^ THE DISEASES OF CHILDREN. 

pneumonia — which leads to it ; perhaps some severe snuffles 
or chronic tonsillitis ; often the rickety conditions in which 
soft bones and a great tendency to bronchitis are combined. 
The student will be well able to suggest himself the many 
conditions under which collapse occurs. It must also be 
remembered that in very young children it sometimes comes 
on with alarming rapidity— a mild bronchitis may perhaps 
have lasted^but a few hours, when the child becomes pale, 
with bluish lips, hurried and shallow respiration, and the 
chest-wall receding during inspiration. 

Symptoms. — When it occurs within the first few weeks of 
life, the child with collapse is of puny build, often wasted, 
and with a weak whining cry. The chest movements are 
shallow, and there may be a want of resonance about the 
bases of the lungs without any decided tubular breathing. 
In cases, also, of great debility there is the same shallow 
respiration, but usually of sudden onset a short time before 
death. In other cases where collapse of the lung is the 
result of pneumonia or bronchitis, the symptoms are mingled 
with those due to these diseases. In cases of extensive col- 
lapse of some duration, the lips may be blue, the fingers 
clubbed, the sternum protruding forwards, and the ribs 
deeply depressed and concave outwards in the lateral region 
of the thorax and below the nipples. Posteriorly the chest 
is rounded, possibly deformed, and on inspiration the whole 
of the lower part of the chest makes a marked movement 
inwards towards the median line, increasing the depression 
already existing. Percussion in such cases may give some 
slight loss of resonance in the basal regions, below the 
scapulae. Possibly, on auscultation, some subcrepitant rales 
may be heard. In cases of long standing the right side of 
the heart becomes dilated and thickened, and the cyanosis 
is not only extreme but persistent. It is remarkable, how- 
ever, how little the heart suffers in proportion to the amount 



ATELECTASIS — PHTII ISIS. 357 

of disease that is present. This is explained by bearing in 
mind that cases which seem to be of long standing are often 
not so. A child's chest is so soft and yielding that it will 
alter in shape within a few days, and one of the most dis- 
torted chests I have seen had assumed that condition within 
a month. Another reason is that defective aeration of blood 
in childhood carries with it defective blood-formation, 
defective nutrition, development, and wasting — and many 
such children are dreadfully thin. The right side of the 
heart is therefore eased of the distension which would of 
necessity follow the same amount of pulmonary obstruction 
in a fuller habit. Atelectasis, by hindering the blood cur- 
rent, may prevent the closure of the ductus arteriosus and of 
the foramen ovale. And here it may be mentioned that it 
is more than probable that atelectasis, by leading on to 
broncho-pneumonia and cheesy changes in the collapsed 
parts, is no uncommon source for the dissemination of tu- 
bercle. I have seen this so often in connection with the 
middle lobe of the right lung as to have very little doubt 
upon the point. 

Morbid Anatomy. — The lung puts on a variety of appear- 
ances according to the extent of the disease. It may be in 
scattered patches, or confined to the hinder part of the lung, 
or to one or other lobe; but the aspect of the atelectatic or 
collapsed part is in all cases much the same. It is shrunken 
below the level of the air-containing lung, or, in the case of 
a whole lobe, there is much diminution in size. It is blue 
or leaden in color upon the surface, and the pleura looks 
thickened. It is not really so ; the feeling imparted to the 
fingers being rather that of a flaccid spleen. There is no 
crepitus ; the tissue is quite flaccid, but solid ; and scattered 
throughout are felt a number of more or less shotty bodies, 
which on section turn out to be thickened bronchial tubes 
and septa. The section is of a uniform dark claret color, or 



358 THE DISEASES OF CHILDREN. 

may be streaked with leaden lines of fibrous septa. It would 
be uniform in surface but that the thickened gelatinous- 
looking bronchial tubes project slightly. The tubes are 
dilated, and often contain much pus. The diseased parts 
sink readily in water, and will often expand lobule by lobule 
when the lung is inflated by bellows. When the disease is 
one of small disseminated patches, then the fawn or buff 
tint of the spongy lung is studded with small raised irregular 
patches of pellucid-looking bluish or leaden-tinted tissue, 
the central part of each of which is a bronchial tube, with 
its swollen mucous membrane raised above the surrounding 
retracted lung. In these cases there is often much bron- 
chitis (pus in the capillary tubes), and those parts not col- 
lapsed may be emphysematous and over-distended with air. 
The histology of these patches of collapse is even of more 
importance. Take it in its disseminated and earliest form, 
where the small grayish nodules are scattered through the 
lung, and we find that around the terminal bronchioles the 
pulmonary vesicles are simply flattened together, presenting 
the appearance, at first sight, of thickened septa. There may 
or may not be some thickening of the walls of the bronchi. 
But in the large masses of more solid tissue the changes are 
those not only of simple closure, but also of interstitial 
inflammation. The pleura is thick ; the fibrous septa between 
the patches and the adjacent lung — for the diseased parts are 
often shut off from the healthy lung in a very definite way 
by these septa — are much thickened ; and not only so, there 
is clearly considerable activity of cell growth in the lymph- 
atic elements around the small bronchioles, so that collec- 
tions — such as have been called miliary abscesses, though 
the term is a bad one — are to be seen in all parts of the 
section, and I think there can also be no doubt that the 
whole area becomes, so to speak, glued together by a process 
of diffused interstitial cell growth. 



1 



ATELECTASIS — PHTHISIS. 359 

These changes seem to me to be of immense importance 
with reference to the results which may accrue from atelec- 
tasis, because they seem to show that when collapse has 
existed for some time a chronic interstitial pneumonia 
results, and the foci of cell growth which are scattered 
about the sections suggest, without any knowledge of the 
clinical course, that caseous or degenerative changes are not 
unlikely to follow. That this actually does happen, and 
that these foci are apt to become the source of the dissem- 
ination of tubercle, is exceedingly probable from the fact 
that the middle lobe of the right lung, a part unusually 
prone to collapse, is very liable to become after whooping- 
cough — a disease particularly liable to produce collapse — 
the seat of cheesy broncho-pneumonia and to be associated 
with a subsequent development of tuberculosis. 

In old-standing cases the right side of the heart is dilated 
and thickened ; it may be fatty ; the pulmonary artery is 
dilated and thickened. The liver is large, firm, and a little 
speckled with fawn-colored points of fat. The spleen is 
firm, and the kidneys have a peculiar india-rubber-like con- 
sistency. • 

Diagnosis. — The chief difficulty lies not so much with 
the disease itself, as in being certified of the absence of other 
conditions. For instance, in very young infants a purulent 
effusion in one or other chest may easily be overlooked in 
the evident collapse of the lung which it determines. 

Prognosis. — Perhaps no cases can look worse and less 
hopeful than those of extreme atelectasis ; but it is to be 
remembered that these appearances can be quickly produced, 
and may all disappear when the cause of the collapse is 
removed. A chest that has all the appearance of permanent 
distortion, will resume a nearly natural shape as the lung 
beneath becomes gradually expanded. Collapse of the lung 
should, therefore, if possible, be remedied as soon as may 



360 THE DISEASES OF CHILDREN. 

be, for the longer it lasts the more chance is there of chronic 
changes in the lung succeeding, and proving a great hin- 
drance to the restoration of the thoracic contour. The grad- 
ual recovery of the natural shape of the chest is one of the 
surest means of judging; and, on the contrary, if the sides 
of the chest remain flattened, and the sternum becomes more 
pointed or bulging, so is the indication that the bases of the 
lungs are not opening out, and that the anterior parts are 
becoming emphysematous. 

Treatment. — All predisposing causes of collapse must be 
vigilantly sought for and treated. Chief of these are im- 
proper food, bad hygiene, and congenital syphilis. These 
determine rickets, and the soft bones of rickets invite the 
occurrence of collapse. Any indications of debility, in what- 
ever form they may show themselves, must be treated in the 
requisite way. The immediate cause of collapse is obstruc- 
tion to the ingress of air, and bronchitis and broncho-pneu- 
monia being — in young children, and most of all in those 
that are rachitic — the commonest cause of obstructed respi- 
ration, require early recognition and careful treatment. As 
a rule, the expectoration of mucus from the bronchial tubes 
is best facilitated by alkaline remedies — such, e. g. y as the 
bicarbonate of potassium — and by stimulating expectorants, 
such as carbonate of ammonium and squills. If there be 
much accumulation of mucus, an emetic of mustard and 
water, or five grains of powdered ipecacuanha, may be 
administered. The child must be kept in bed, and in a 
warm equally-heated room, the atmosphere of which is 
moistened by the steam from a bronchitis-kettle. Unless 
there be fever, there will be no necessity for poultices. The 
chest may be lightly wrapped in a thin wool jacket, a warm 
bath given from time to time, and stimulating liniments ap- 
plied to the surface. It is unadvisable to wrap the child up 
too much, as this provokes much perspiration and reduces 



ATELECTASIS — PHTHISIS. 36 I 

the strength. At the same time, in fatal atelectasis the body 
temperature is apt to fall very low, and in such cases the infant 
should be thoroughly encased in wool. As soon as possible, 
quinine, iron, and cod-liver oil, or cream, should be admin- 
istered, and plenty of bathing and friction to the muscles of 
the body, either with simple oil inunction or cod-liver oil, 
the only objection to the latter being its nastiness. Elec- 
tricity has been recommended to improve the tone of the 
muscles and thereby to accelerate the recovery of the col- 
lapse, but it is a remedy which is not easy of application in 
young children, the sensation frightening them too much, 
and I believe it is better to trust to good rubbing and 
kneading night and morning. 

Phthisis. — I do not intend to discuss the vexed question 
of the nature of phthisis. I shall proceed upon the state- 
ment, which is certainly abundantly proved, that in the great 
majority of cases of destruction of the lung by caseous 
changes, tubercle and cheesy softening in various stages are 
found in the same lung, and, to simplify matters, I shall 
speak of them all as tubercular. In this respect, phthisis in 
children does not differ from the disease as met with in 
adults, save that in the former case the rule is even more 
absolute, but the pattern or distribution of the disease in the 
lung is less uniform. If we exclude doubtful cases of early 
apical disease in children, it has certainly not been common 
in my experience to meet with changes which have excavated 
the lung from above downwards as is seen so constantly in 
adults. Any one with large experience amongst children 
will no doubt meet with such cases not so very infrequently, 
but other cases are more common, in which there is no cavi- 
tation, or the lung is attacked less regularly. These appear- 
ances will be described directly under their morbid anatomy, 
but I will say here that such differences as exist largely de- 
pend upon the physiological standard of growth which ob- 



362 THE DISEASES OF CHILDREN. 

tains in infancy and childhood. For example, in malignant 
tumors in childhood — whether they be of testis, or kidney, 
or liver, or what not — we do not expect to find a slowly 
growing disease, such as is ofttimes found in adults. The 
processes are active, and the growth, wherever it be, rapid. 
And so it is with tubercle. It runs its course more rapidly; 
and thus we have often more to do with miliary tubercu- 
losis, with solidification by gray tubercle, with gray tubercle 
softenening into yellow in a miliary manner, and but seldom 
with any large cavities. In the same way, the fibrous forms 
of disease are less frequent, and other, forms develop by rea- 
son of the proneness in infancy to degenerative changes in 
the lymphatic glands. 

The tubercular appearance is generally made much of in 
phthisis in children ; and we are all familiar, no doubt, with 
the description of the pretty child, with its well-formed 
skeleton, its soft hair, long eyelashes, peach-like skin, good 
nails and teeth, and intelligent mien — and with its antitype 
of coarseness, the pale, sallow, stunted, thick-skinned child, 
who goes the same way, albeit, perhaps, by a modified route 
of scrofulous glands. These types have sprung out of expe- 
rience, and should be well remembered. But the student's 
difficulty will be that he is unable to push these definitions 
sufficiently to be of use to him, and as soon as he seeks to 
be enlightened, not upon the tubercular appearance but 
upon the distinctions between it and others — particularly 
that which is called by some the rheumatic conformation — 
so that he may be able to say this is one thing, this certainly 
another, he finds his teacher fail him. Types of this kind 
will not bear too close a scrutiny; it would puzzle any one 
to distinguish many a rheumatic child from a tubercular one. 

The shape of the chest in tubercular subjects has been 
alluded to by most writers, and Hillier, who is too good an 
observer to be ignored, describes three typical forms : (1) the 



ATELECTASIS PHTHISIS. 363 

long, circular chest; (2) the long chest, with narrow antero- 
posterior diameter ; (3) the long, pigeon-breasted chest. I 
cannot say that I am sure of these ; it has seemed to me that 
a rachitic chest is too frequently the cause of collapse, and 
of subsequent cheesy and tubercular changes, to make the 
distinctions of great value. Tubercular chests are small 
chests with the apices contracted. 

The symptoms of pulmonary tuberculosis in children are 
often most obscure. In the early stages they are those which 
the one shares in common with other diseases, and notably 
that condition to which Dr. Eustace Smith. has given the 
name of mucous disease. The child is pale, thin, capricious 
in appetite, and has a dry cough; the bowels are irregular, 
he perhaps may even have worms. All these are conditions 
which are often neglected as temporary derangements. The 
temperature is not taken at night, and perhaps a case thought 
to be mucous disease develops acute tuberculosis and the 
child dies rapidly, whilst one as to which suspicions of 
phthisis are entertained gets well. This uncertainty is in 
great measure due to the ambiguity which attaches to the 
physical signs. It takes several very careful and complete 
examinations to be sure of an early tuberculosis, and even 
then it is sometimes impossible to avoid mistakes. . The 
beginner will find, if he looks back upon his notes in after 
years, that a large majority of his early cases raised the 
question of phthisis, which subsequent experience solved by 
the restored health of the children. In looking over my 
own notes, I find that no less than 152 out of a total of 233 
must be considered doubtful. There was dulness at one or 
other apex, some clicking crepitation, deficient movement, 
or bronchial breathing, but which has never come to any- 
thing, and in most of which what seemed certain at one 
examination was very uncertain subsequently. One passes 
through phases of experience : at first, all cases are phthis- 



Advanced 


Doubt- 


Phthisis. 


ful. 


2 


1/ 


IO 


14 


7 


IO 


4 


14 


9 


18 


8 


IO 


2 


21 


5 


13 


3 


15 


2 


8 


O 


13 



364 THE DISEASES OF CHILDREN. 

ical ; a riper experience shows advanced phthisis to be com- 
paratively rare. Of the 233 cases mentioned, 64 were pro- 
nounced cases; 17 others were cases of acute tuberculosis. 
The ages of such as are detailed are as follows : 

Acute 
Tuberculosis. 
Under i, ....... 4 

1 to 2, 3 

2 " 3, 2 

3 " 4, o 

4 " 5. ■ 

5 " 6, o 

6 " 7, 1 

7 " 8, 1 

8 " 9. o 

9 " 10, o 

Over, o 

No age is exempt from acute tuberculosis. In infants 
only a few weeks old one or other apex will sometimes 
become suddenly dull, and the child die off with the lungs 
studded with tubercle within a short time. Nevertheless, it 
becomes common as the period of dentition is reached, and 
then it is that a disseminated form of tubercle, associated 
with cheesy bronchial glands, is so common. 

Morbid Anatomy. — All forms of tubercle, or rather tuber- 
cular inflammation, are met with in the lungs of children, and 
they are all more or less found together ; but for practical 
purposes, I think we may distinguish four groups of cases, 
viz.: (1) those in which the disease is chiefly, often entirely, 
a miliary tuberculosis ; (2) those in which there is a con- 
glomerate form of gray and softening tubercule— perhaps 
yellow and gray infiltration — and cheesy bronchial glands ; 
(3) a more chronic form, with cavitation and fibrious 
changes ; and, (4) cheesy solidification. It is difficult to 
obtain figures to tell the relative frequency of these groups. 



ATELECTASIS — PHTHISIS. 365 

The conglomerate form has been the commonest in my ex- 
perience, miliary tuberculosis next so, and the others far 
behind. Some authors describe still further a fibroid form 
of phthisis. I have once met with a peculiar fibroid form 
of phthisis without tubercle, in a boy of thirteen, who came 
under the care of Dr. Pye-Smith, and the case is recorded 
by him in the " Transactions of the Pathological Society of 
London," vol. xxxiii. The appearances in the lung aiKl 
liver, which was cirrhosed, were to my mind very sugges- 
tive of old syphilis. But Dr. Barlow has met with more 
than one very similar case, and without any history of 
syphilis ; and no doubt cases of this kind occasionally hap- 
pen, the cause of which is obscure. There is, however, a 
more common condition, which I have already described, 
where the base of the lung is solid and the bronchial tubes 
dilated; but this is certainly most commonly due to some 
bygone pneumonia or pleuritic effusion. 

There is no need to go minutely into the morbid appear- 
ance of the lungs in the several classes of cases, as the 
minute changes do not differ from tubercle, as seen in adults, 
but one or two peculiarites may be mentioned. In the first 
place, the individual granules of miliary tubercle vary much 
in size, and are sometimes so minute as to escape detection 
upon superficial examination. This is particularly the case 
where death has come about rather rapidly by tubercular 
meningitis, and it may serve to impress attention upon the 
fact that the lungs may be perfectly free from any pneu- 
monic changes, and consequently that miliary tubercle of 
this kind is beyond detection by physical examination dur- 
ing life. Its presence can then, indeed, only be suspected 
by the existence of bronchitis in association with other con- 
ditions which make for the existence of tubercle. 

Next, it should be noticed that the distribution of tuber- 
cular disease is more irregular in the lungs of children. It 

31 



366 THE DISEASES OF. CHILDREN. 

is more common to find it distributed throughout the lung 
than at the apex and from thence downwards, and it is also 
very common to be able to trace a rough localization of the 
disease about the root of the lung, whilst there is certainly 
less evidence of the extension by continuity of tissue which 
is so common in adults, though perhaps more of clustering 
around, and extension along the bronchial tubes and septa. 
Again, the existence of cheesy bronchial glands of consid- 
erable size and fleshiness is far more common in children 
than in adults, and last, but not least, there is an allied dis- 
ease which I have met with several times in children — 
never, so far as I remember, in adults — and to which I have 
given the name of cheesy consolidation of the lung. The 
most remarkable example of this affection that I have seen 
was in a child of two years under Dr. Moxon's care at 
Guy's Hospital. The whole of the left side of the chest 
was dull, and there had been a question of the existence or 
not of pleuritic effusion. At the post-mortem examination, 
nearly the whole of this lung was converted into a solid, 
firm, cheesy mass, quite like an enlarged and cheesy bron- 
chial gland which has undergone no softening. Towards 
the front of the lung there was a little spongy tissue remain- 
ing, and studded rather thickly with yellow tubercles, whilst 
the other lung was crowded with tubercles. A similar form 
of disease, but less extensive, in which a part of one lobe 
has been diseased, I have seen several times, and it is due, 
I believe, to a gradual growth into the lung from the cheesy 
bronchial glands at its root. 

It need hardly be insisted how these points in the mor- 
bid anatomy are corroborated by, and in their turn enlighten 
and emphasize the physical signs of pulmonary tuberculosis. 
They show why it is that the physical signs are so often 
obscure, for, if the disease begins by preference at the root 
of the lung, it will long be covered by vesicular structure, 



ATELECTASIS — PHTHISIS. 367 

and the more distinctive features will want that constancy 
which will alone allow of precision in diagnosis. They will 
show, too, how carefully the chest must be examined, inch 
by inch, so that the small patches of disseminated softening 
so often present may not escape detection ; how with the 
enlargement of the bronchial glands in the posterior medi- 
astinum and the extension of disease from them, the inter- 
vertebral grooves must be carefully examined by percussion 
and auscultation, and the resulting sounds most carefully 
weighed with our experience of those of health. 

I have already alluded to a child in whose case for three 
weeks great uncertainty existed as to whether his disease 
were typhoid fever or tuberculosis, but which turned out to 
be the latter. The physical signs of disease at the root were 
not of the most distinct, but they were there, and, looking 
back upon the case, it seems probable that with a suspi- 
ciously wandering dry pleuritic rub, and slight intolerance 
of light they were not insufficient to have determined the 
diagnosis had their value been rather more judicially ex- 
amined. These cases frequently require all one's powers 
of mind, a rigorous examination, and the most impartial 
analysis of symptoms, to enable one to arrive at a right 
conclusion. 

The other viscera should always be examined in question- 
able phthisis ; it may be that an enlargement of the liver or 
spleen may be detected, possibly some early tubercular dis- 
ease of the choroid. Such cases as follow are quite com- 
mon. A female child aet. seventeen months : The lungs 
were studded with recent tubercular pneumonia, but in 
addition there was much caseous enlargement of the bron- 
chial glands, numerous tubercles in the liver and spleen, 
general cheesy change in the mesenteric glands, and tuber- 
cular ulceration of the intestines. 

A boy aged one year : The lungs were stuffed with gray 



36S THE DISEASES OF CHILDREN. 

tubercle in a state of early caseation, the bronchial glands 
were much enlarged, and there were tubercles in the 1 
spleen, and kidneys. 

Complications. — Death occurs in most cases amongst 
nger children through the outbreak of a general or 
acute tuberculosis, and the extension of the disease to the 
brain and its membranes. Thus we may find tuberc 
meningitis, yellow tubercle in the cerebellum or otlier 
parts ; as well as tubercle of the organs already mentioned, 
of the peritoneum, and elsewhere. In older children, wi- 
the disease becomes very chronic, the same results are met 
with as in adults, viz., lardaceous disease of the viscera, 
fatty liver, tabes, and intestinal or laryngeal ulceration. 

Diagnosis. — In any case of apical disease caution is 
necessarv in coming to a conclusion. Over and overa^ain 
the physical signs which denote cons n pass away. 

Acute pneumonia running a rather more chronic course 
than we think it should do, arouses our fears only to dispel 
them. Pleuritic effusion gives rise to rather persistent tu- 
bular breathing at the apex. This, again, clears up, if we 
only give it time, and it is my distinct belief that there is 
many a local disease at the apex, both parenchymatous and 
pleuritic, which arouses exaggerated fears only by its posi- 
tion. Localized pleuritic effusions, both serous and puru- 
lent, may take place below the clavicle as well as at the base, 
and if there be any doubt upon the point, this part as well 
as the base should be explored by the hypodermic syringe. 
It is, indeed, hardly possible to insist too strongly upon the 
necessity of always being on the watch for the presence of 
fluid, and particularly of pus. Empyema is so common in 
children, and so frequently puts on many of the appearar 
of phthisis that mistakes are quite common. The case 
should be examined repeatedly if there be any doubt, 
temperature taken regularly, and the body weight at suffi- 



ATELECTASIS — PHTHISIS. 



369 



cient intervals. After whooping-cough, too, the physical 
signs are most puzzling. There are plenty of coarse mucous 
rales and patches of tubular breathing down the front of the 
lungs and round the nipples, and the excessive wasting 
makes one apprehensive. Nevertheless, we must not be too 
hurried in coming to a positive conclusion. 

Prognosis. — Pulmonary phthisis is in most cases capable 
of improvement, says Gerhardt ; and there can be no doubt, 
as I have said, that many cases, too hastily condemned as 
cases of consumption, improve and even get quite well. 
The frequency with which scars, relics of various kinds, cal- 
careous and other, are met with in the lungs of older people, 
proves conclusively that many of the changes which consti- 
tute phthisis are reparable if not too extensive. But perhaps 
the most irrefragable evidence of the possibility of repair of 
tubercle has been offered since the peritoneum has been 
dealt with by the greater boldness and success of latter-day 
surgery. Cases are on record where tubercular granulations 
have been seen upon the peritoneum during operations, and 
the patient has subsequently recovered. There is other 
evidence, hardly less strong. Some time ago I made an 
inspection upon the body of a lady under Dr. Habershon's 
care, who died of tubercular meningitis. Many years before, 
w r hen a girl, she had been supposed to suffer from tubercular 
peritonitis, and w r e found, in accordance with that view, that 
the intestines were all matted together by old adhesions, and 
the greater part of the mesenteric glands converted into 
chalky concretions. The finding calcareous glands in the 
abdomen is no uncommon experience to those engaged in 
making frequent necropsies. Therefore it may be accepted 
as certain that tubercular disease is sometimes amenable to 
treatment. At the same time, it is to be remembered that 
these cases may ameliorate for a time, and then suddenly 
develop acute meningitis or general tuberculosis ; and that 



370 THE DISEASES OF CHILDREN. 

if they do not show any tendency to improvement, the course 
of the disease in children is habitually shorter than it is in 
adults. 

Treatment. — The essentials of treatment are good feeding 
and good air. The first presents difficulties in all classes of 
life ; the latter chiefly for those to whom money is an object 
of concern. The appetite is generally capricious, vomiting 
is often troublesome, and these patients cannot take fats. 
They do well upon a rich diet, if it can be borne, and they 
should be encouraged to take plenty of good milk, cream, 
suet, and milk and eggs. Plain beef and mutton, nicely 
cooked, are most nourishing, but in many cases fish, oysters, 
soups, etc., are requisite to vary the diet and tempt the ap- 
petite. Small quantities of stimulant are of unquestionable 
value. It may be given as stout, or bitter ale or wine, with 
food. In sucklings, if there be any delicacy about the 
mother, the child should either be fed artificially or supplied 
with a wet nurse. The air of large towns is unquestionably 
harmful, and children with any suspicion of phthisis should, 
if possible, be removed to a dry seaside place, and have as 
much out-of-door air as possible. Every possible attention 
must be paid to the general health, and the rooms in which 
the child lives and sleeps must be well ventilated. Damp 
is reputed to be injurious, whether associated with warmth 
or cold. Cold and damp combined are certainly prejudicial, 
and there is also a tendency in these cases to w r eather a 
winter and then suddenly to deteriorate as the showery warm 
weather at the end of spring comes in. Cold weather, if dry, 
is often most serviceable for early cases. The soil should be 
dry and the place protected from the colder north and north- 
east winds. The clothes must be warm. Of drugs, cod- 
liver oil, by common consent, is of great service, and what 
with tasteless oil, almondized oil, biscuits in which the taste 
of the oil is almost completely concealed, and capsules, a 



ATELECTASIS — PHTHISIS. 37 I 

great many children, with whom there was difficulty, can 
now take it comfortably. It may be given in water, orange 
wine, milk, or coffee, indeed, in any way that may suggest 

itself, and the dose is to be increased from half a teaspoonful 
up to two or more. 

[The following is a very good formula: 

R. 01. Morrhuce fgiv. 

Ext. Malt (dry), gj. 

Calcii Hypophos., 

Sodii Hypophos., . . . . . , aa gr. xxxii. 

Potassii Hypophos., gr. xvj. 

Glycerine, ....... fgss. 

Pulv. Acaciae, . . . . . . gss. 

Aquae, q. s. ad f gviii. M. 

S. — Two teaspoonfuls three times daily, for a child of six years.] 

Such children are often very anaemic, and arsenic is there- 
fore useful. It may be given in five or six minim dos 
with some simple syrup, or with benzoate of sodium, syrup, 
and water (F. 42). Many other remedies have been recom- 
mended which it would be impossible to mention. The 
most useful are, I think, the chloride of calcium — which 
should be given in doses of five to ten grains in some ex- 
tract of liquorice, glycerine and water, three times a day for 
a long period — and iodoform, which I have latterly been 
trying on germicide principles. It must be given cautiously, 
in half-grain or one-grain doses up to two grains or more, 
with white sugar, in a powder. Some children take it very 
well, others badly; some it makes sick, delirious, and ill. 

Counter-irritation may be produced by a mustard-leaf, or 
some linimentum iodi, but in all cases it is to be remem- 
bered that a child's skin is very tender and easily vesicates. 

For the cough, some simple expectorant may be given, 

* Fowler's solution. — Ed. 



372 THE DISEASES OF CHILDREN. 

and when there is much night perspiration belladonna is by 
far the most reliable remedy. Twenty drops may be given 
to a child of four or five at bedtime, or a smaller dose may 
be added to each dose of any compatible medicine that it 
may be taking during the day. 

I have once seen fatal haemoptysis in a child of three or 
four years from an aneurism on a branch of the pulmonary 
artery in the wall of a cavity. But haemoptysis is not com- 
mon. Should it occur, small doses of turpentine — e.g., five 
or six drops of the oil — may be given with some mucilage 
of tragacanth, syrup, and dill-water. 



PLEURISY. 



373 



CHAPTER XXIV. 

PLEURISY. 

Pleurisy is a very common disease, and is a particularly 
important one, if for no other reason than this — that the 
fluid effused is so frequently purulent. I have notes of 149 
cases, gathered from all sources of my own practice. Of 
these, 71 were simple, 78 were purulent. This can, per- 
haps, hardly be considered a fair average, for a hospital 
physician is naturally likely to see the worst side of all 
diseases. 

The subjoined facts may be of interest: 



Age. 










Simple. 




Purulent 


Under 1, 6. . .4 


Between 1 and 2, 










15 






13 


2 " 3, 










II 






9 


3 " 4, 










7 






13 


4 " 5, • 










6 






10 


" 5 " 6, 










6 






12 


" 6 " 7, 










6 






4 


" 7 " 8, 










2 






5 


" 8 " 9, • 










1 






2 


" 9 u 10, . 










3 






3 


" 10 " 12. 










4 






3 


Not stated, 










4 










71 



SEX. 



78 



Simple pleurisy occurred 31 times in females. 

" " " 40 " in males. 

Empyema " " 35 " in females. 

" " " 43 " in males. 

Fibrinous pleurisy affected the right side 28, the left side 

43 times ; empyema, the right 18, the left 59 times ; one case 

was doubtful. 

32 



374 THE DISEASES OF CHILDREN. 

The large preponderance of left-sided empyema over right- 
sided, four to one, is worth remembering. 

Pleurisy is usually stated to be most commonly a second- 
ary disease, and, if we consider how many causes lurk in 
diseases of the surrounding structures, we shall not wonder 
that it is at any rate, not unfrequently dependent upon dis- 
ease of those parts. Tubercular disease of the lung ; acute 
and chronic pneumonia ; bronchitis ; dilated bronchial tubes ; 
disease of the bronchial glands ; pericarditis ; inflammatory 
conditions below the diaphragm, such as localized abscesses 
between the liver and diaphragm, or the spleen and dia- 
phragm; general peritonitis; disease of the spine and ribs — 
these are some of the many affections which may set up 
pleurisy. Less obvious in their actions, but frequent as 
causes, must be reckoned scarlatina and rheumatism — the 
latter of acute fibrinous pleurisy, the former of empyema. 
The importance of both these affections as causes of pleurisy 
is, I believe, not fully estimated ; but when all is said with 
reference to the causes of pleurisy, there will remain a large 
number, in my experience the greater number, in which it 
has not been possible to assign any cause, and I should 
therefore be disposed to think that idiopathic pleurisy is not 
so very uncommon. 

Pleurisy may lead to the formation either of lymph, or 
serum, or pus. It is impossible to make any useful distinc- 
tion between those cases in which the exudation is fibrinous 
and those in which it is serous, or, to put it in other words, 
between those in which there is effusion and those in which 
there is none, the reason being, that in children the forma- 
tion of lymph is so active that the presence of fluid is often 
suspected where the exploring syringe shows the opinion to 
have been unfounded. In the treatment of empyema, a 
knowledge of the existence of this excess of lymph is of the 
greatest importance. 



PLEURISY. 



375 






Symptoms. — As a rule they are not very acute, even in 
simple (non-purulent) pleurisy, although there is a definite 
onset. Pain in the side is common, but it often needs to be 
inquired for. Fever, wasting", want of appetite, languor, and 
cough are the more usual symptoms complained of. Head- 
ache, vomiting, convulsions, and diarrhoea are also occa- 
sional symptoms. The time at which the child has been 
brought for treatment has been very variable, from two or 
three days to as many months. This will serve to show 
that the acuteness of onset is liable to vary considerably ; 
and I would further say that occasionally the onset is so 
acute as almost to deserve the name of violent — the fever 
being high, delirium considerable, and the pain in the side 
apparently an agony. These cases are quite likely to be 
mistaken for an acute pneumonia, of which, indeed, it would 
be impossible to deny the existence in some measure, and 
they are, in my experience, very likely to be quickly fol- 
lowed by the rapid and copious effusion of pus. The tem- 
perature in pleurisy is of no characteristic type — it is often 
up to ioi°, 102°, or 103 in the first day or two (in the 
very acute cases higher), in the afternoon or evening, and 
the pyrexia may be prolonged. I have several times enter- 
tained unfounded fears for the formation of pus from this 
prolongation of the pyrexia. It is difficult to get any large 
number of cases in which the disease has been uncom- 
plicated and watched from the commencement as regards 
this point. In eleven cases the temperature has averaged 
not much over ioo° after the first onset, although occasion- 
ally in several of these making erratic excursions. 

In infants, pleurisy is apt to produce a pinched and col- 
lapsed condition, like peritonitis in the adult. 

When the fluid is purulent, excepting in the very acute 
cases already alluded to, the onset is still more indefinite 
than when the products are serous. In this respect, again, 



3/6 THE DISEASES OF CHILDREN. 

the pleura may be compared with the peritoneum, in which 
the fibrinous or plastic inflammations are very generally 
acute, painful, and not to be mistaken ; the purulent inflam- 
mations are apt to be overlooked, by reason not so much of 
their lack of symptoms as of the vagueness of those symp- - 
toms which occur. Nevertheless, commencing, as the dis- 
ease often does, in acute pneumonia and other evils, a sudden 
onset is noticed in many cases. Of fifteen cases, in eight 
the child was suddenly taken ill ; in seven, the onset was 
indefinite after mumps, or scarlatina, or pertussis. Of gen- 
eral symptoms likely to be present in empyema, emaciation 
is often rapid and extreme. I once saw a child, a few 
months old, wasted to the last degree, with a moderate 
quantity of fluid in the left chest. The wasting seemed to 
be too extreme for pleurisy alone, and nothing was done to 
remove the fluid. The child died the next day, and the 
post-mortem examination revealed nothing but an empyema. 
There may also be much pallor, and sometimes a puffy ap- 
pearance of the face, such as suggests Bright's disease. 
This latter symptom I believe to be sometimes a most 
valuable one as indicating the existence of fluid in the chest, 
and, in the absence of renal disease or pertussis, pleuritic 
effusion should be thought of. Moreover, it is a symptom 
which indicates a large effusion, and I have seen cases where, 
except for this sign, the auscultatory and other phenomena 
were in favor of pneumonia. This symptom is not con- 
fined to empyema ; it may accompany any large pleuritic 
effusion. 

Here, again, the temperature is not to be trusted implicitly. 
As a rule, it rises by night ; and I have noticed that the 
suppurative fever is apt to register with particular delicacy 
the reaccumulation of pus when it has been removed by 
operation. It is by no means uncommon to find oneself in 
considerable doubt as to the presence of pus in empyemas 



PLEURISY. 



377 



which have not been tampered with ; but after the pus has 
been evacuated, should it again reaccumulate, the thermo-' 
meter will indicate the fact with the most sensitive accu- 
racy. When there is much emaciation, and the disease is 
chronic, there may be no elevation at all. Sometimes, while 
on the whole normal, sudden jumps will be made at night; 
but, in this, empyema accords with serous effusions, which 
are liable to behave in the same manner. It may be said, 
again, that we must be cautious how, in pleuritic effusions, 
we conclude as to the purulent nature of the complaint from 
the evening rises of temperature, for these sometimes occur 
night after night for a considerable period in cases where 
no pus can be withdrawn. Diarrhoea is, also, a valuable sign 
of the existence of pus in the pleura, and the same remark 
applies to sweating. 

There is one other negative sign to which it is well worth 
while to draw attention, viz., the absence of any indications 
of distress in breathing. Such a thing might otherwise be 
thought impossible with one or other side of the chest full 
of fluid. Yet not only may this be so, but even the heart 
may be considerably displaced without symptoms. This 
is noticed in the more chronic cases, and is not difficult to 
explain. A like phenomenon is present in many cases of 
phthisis, and it is dependent in great part upon the com- 
pensation which takes place as the disease progresses, the 
emaciated body requiring diminished action of the lung. 

Physical Signs. — There are several difficulties in the 
detection of fluid in a child's chest, which are far less 
perplexing in adults, and pleurisy in children requires 
therefore the greater care. It is frequently overlooked or 
misnamed. The presence of fluid in a child's chest is very 
often only established by the concurrence and correct ap- 
preciation and interpretation of several slight indications. 
It is therefore necessary to pay attention to slight deviations 



3/8 THE DISEASES OF CHILDREN. 

from the normal. A careful inspection tells us that one 
side is moving less well than the other; the lessened range 
of movement may be considerable — if so, so much the 
better for the diagnosis ; the affected side is rather more 
flat, or appears generally contracted. In very chronic 
cases the spine may be bent towards the diseased side. 
This contraction of the chest may sometimes be verified by 
the cyrtometer, but exact measurements of the size and out- 
line of the chest are difficult to make and very liable to 
lead to a wrong conclusion. Bulging of the ribs and inter- 
costal spaces is said to be an indication of the existence of 
pus. It is more common to find the measurement of the 
affected side natural, smaller, or distorted, than over-dis- 
tended. 

If the chest be full of fluid, there may be complete dul- 
ness all over the affected side, the heart will be more or less 
displaced (one of the most valuable of all signs of fluid in 
the chest), and the case will present no difficulties. But 
such cases are not common. Fewer mistakes will be made 
if, on the contrary, we look to find modified resonance, not 
dulness, at the apex of the affected side. But comparing 
the one apex with the other, the resonance will not be the 
natural deep resonance, but a high-pitched tympanitic note. 
Whenever this quality of sound is present, the first thought 
should be — Is there fluid at the base of the chest ? 

Pleurisy at the base is the most common cause of dimin- 
ished or tympanitic resonance at the apex, in children. Oc- 
casionally this is due to pneumonia or to some consolidation 
at the apex itself. But should there be any dulness at the 
base, stronger evidence than usual is necessary to convince 
us that there is really any disease at the apex. 

The tympanitic note at the apex is a physical sign which 
has attracted much attention, and the mode of its produc- 
tion has been often discussed ; it is spoken of sometimes as 



PLEURISY. 379 

the bruit Skodique, or Skoda's tympanitic resonance. This 
is usually attributed to condensation of the apex of the lung, 
but it is obvious that condensation — partial, not total — may 
be produced in various ways, and the meaning of tympanitic 
resonance by itself would have to be decided upon the bal- 
ance of probabilities. 

Percussion should be gentle. The chest-walls are yield- 
ing, and it is easy in childhood to displace fluid and get upon 
spongy lung beneath, so as to elicit resonance where there 
should be dulness. 

Then again we must be careful, in dealing with the chest 
of a child, how we apply the teaching which has been gleaned 
from adults. The auscultatory phenomena of fluid in the 
chest are — absence of the respiratory murmur; absence of 
the vocal resonance ; absence of tactile vibration ; and, if the 
compressed lung be near the surface, high-pitched distant 
tubular breathing will be heard. If all these signs are pre- 
sent, the case presents no difficulty; but such, again, are 
exceptional cases in childhood. What is usually heard may 
be illustrated by a reference to the two most common mis- 
takes which are made by students. I am generally told that 
there is bronchial breathing upon the healthy side, or else at 
the apex of the diseased side. It is quite common in these 
cases to hear all over the affected side a soft vesicular mur- 
mur of good quality, but deficient in quantity. If there were 
only the one side to judge from, the difficulty would be 
extreme to say whether disease were there or not, but, 0:1 
auscultating the unaffected side, the exaggeration of the 
inspiratory murmur excites attention — there is apparent the 
so-called puerile breathing; but since "puerile" is applied 
to adult lungs as compared with child's lungs, when com- 
paring the normal child-respiration with the abnormal the 
latter must be called " exaggerated puerile/' The inspira- 
tory murmur is very hoarse and harsh, and the expiratory 



38O THE DISEASES OF CHILDREN. 

is also rather longer than it should be ; but if we gauge the 
length of inspiration and expiration, the latter is not out of 
proper proportion as to length. 

Again, on the diseased side, I am perhaps told, that there 
is bronchial breathing at the apex, and the case is called 
phthisis. Here the observation is correct ; the inference 
from it is wrong. There is often bronchial or tubular breath- 
ing beneath the clavicle on the same side as the effusion, and 
this is only what might be expected. The lung is more or 
less compressed by fluid, and therefore prevented from 
expanding; hence the more or less bronchial, nay, even 
sometimes loudly tubular, respiration, just as there is the 
tympanitic resonance. Again, we have to judge not by the 
single sign, but by several combined. The tympanitic reso- 
nance at the apex first puts us on guard ; then, by careful 
percussion, comparative dulness at the same base is detected, 
and on auscultation bronchial respiration and a soft, distant, 
vesicular murmur, with a diminution of the voice-sounds. 
The latter is often interpreted by the student as broncho- 
phony, on the other side. I take no note of tactile vibra- 
tion, as it is often difficult to make out anything positive 
about this in children, the voice giving but feeble vibrations 
on either side. We may often get no more pronounced 
physical signs than these, and with them we must be con- 
tent. Good though deficient vesicular murmur may be 
present all over the side which is full of fluid, and unless 
this is remembered there is likely to be a mistake in diag- 
nosis. 

But if we have an opportunity of examining a patient day 
by day, another phenomenon will probably puzzle us, and 
that is the variability of the signs ; an examination one day 
reveals dulness and bronchial breathing ; another day there 
is much less dulness, and what may be considered as good 
vesicular murmur : one day the chest looks bulging, another 



PLEURISY. 38I 

retracted ; and these variations are apt to quickly follow each 
other. This is a feature of chest disease in children. The 
explanation is perhaps not easy to give. It may be due to 
the difference of inspiratory power at various times. 

With regard to the bronchial breathing, the presence or 
absence of crackling or bubbling mucous rales in the chest, 
particularly at the apex, should be noticed. In the bronchial 
breathing of condensed lung from fluid in the chest there is 
often for long an absence of crepitation ; and such persistent 
absence of crepitation is one point, in children, in favor of 
the non-existence of phthisis, which is often mistaken for 
pleuritic effusion. 

If death takes place from serous effusion, some tubercular 
or pneumonic affection is usually at the bottom of it. Some 
hold that a serous effusion is the origin of most of the empy- 
emas, and base upon that belief an argument in favor of early 
paracentesis in the former. I think the balance of proba- 
bility is against this view, and in favor of empyema com- 
mencing as such, except in occasional instances. 

Morbid Anatomy. — Death from empyema takes place at 
different periods, and the condition of the pleural cavity will 
vary somewhat accordingly. The chest may be full of pus, 
or there maybe, besides the pus, much thick caseous lymph, 
or the pleura may be loculated by bands of lymph. I have 
even seen serum in one cavity and pus in another. The lung 
may be bound down and quite airless throughout, or one 
part or another may be compressed by fluid. 

Histological examination shows sometimes simple com- 
pression of the lung; sometimes more or less inflammatory 
cell-growth, running along the septa of the lung from the 
pleura inwards ; sometimes nests of cells scattered through 
the bronchial septa, which suggest the possibility of the 
disease having originated in some pneumonic process. 

Complications. — When death takes place during the early 



:Sr THE DISEASES OF CHILD?!; . 

days of the disease, either after operation or not, pericar : 
or inflammation of the connective tissue of the mediastinum 
and of the other pleura, or suppurative peritonitis, are the 
more likely causes. In the later stages, death results from 
exhaustion, lardaceous disease of the viscera, and tubercu- 
losis. 

It must further be added, that it is the belief of many that 
pleuritic effusion, particularly if purulent, is the origin of 
many of the. cases of chronic pneumonia, fibroid pht 
and dilated bronchial tubes, that are met with in later life, 
and probably this is true for some cases. 

Diagnosis. — There are no useful distinctions, as regards 
s cal signs, between pus and serum. The purulent nature 
of the collection may be surmised from the cause — if measles 
or scarlatina, etc., are known to have preceded it, the presence 
of pus is not improbable. Attention should also be paid to 
the general symptoms, of which pallor, pyrexia, sweating, and 
diarrhoea are perhaps the more important. But I have 
several cases of simple serous effusion, in which the temper- 
ature has risen regularly every evening ; some cases of pus, 
in which the temperature has been nearly normal, and pallor 
and sweating are by no means to be relied upon. The 
question can only be absolutely settled by an exploration 
with a hypodermic syringe, a trifling operation which does 
no harm, and generally suffices to clear up our doubts. The 
chest must be carefully examined beforehand, and the needle 
passed in wherever it appears that there is fluid, whether 
this be at the base, as is most common, or in the axilla, or 
even at the apex. I have obtained fluid three times from 
beneath the clavicle when nothing came from other parts. 
There need be no fear of wounding the lung, it would do no 
harm; or, at any rate, thr a mere nothing 

pared with the importance of settling the question of the 
existence of pus. 






PLEURI- 383 

A caution may perhaps be added with reference to the 
conclusion drawn from exploration — viz., that it does not 
always follow that no fluid is in the chest because none 
comes out by the aspirator. There are several conditions 
which now and again militate against the flow of the fluid. 
The lymph within the chest may be abundant and thick, 
whilst the needle is liable to become choked, or to push the 
lymph before it, and thus may never enter the cavity. A 
good deal can, however, be learned, even w T hen no fluid 
comes, by the passage of the instrument, and its behavior 
on gentle manipulation subsequently, whether it is in a 
cavity or not. The risk of failure is somewhat lessened by 
using as an exploring syringe one with a needle tube longer 
and of somewhat larger bore than those made for hypo- 
dermic purposes. 

The next most important diagnostic difficulty is to distin- 
guish between phthisis and pleuritic effusion. The two are 
often mistaken, the pleurisy being called consumption ; but 
in treating of symptoms, enough has already been said to 
enable a distinction to be drawn. Of other conditions, the 
chief are chronic consolidation at the base from pneumonia 
and collapse of the lung. These may perhaps be distin- 
guished by the increase of voice sounds in place of diminu- 
ton; but, as I have said, the vocal sounds, whether auscul- 
tatory or tactile, are of less value in children than in adults, 
and cannot be certainly relied upon. If not, it may be ne- 
cessary to explore by the syringe in these cases also before 
coming to any positive conclusion. It was in a case of this 
kind that the only mishap, and that but a slight one, that has 
ever occurred to me in the use of the exploring syringe came 
about. Directly the needle was passed into the chest the 
child coughed up, perhaps, two drachms of bright red blood. 
It came so quickly, indeed immediately, upon the introduc- 
tion of the needle, that I feared some large branch of artery 



384 THE DISEASES OF CHILDREN. 

must have been punctured, but no further ill-results accrued, 
and no more blood came. 

Prognosis. — Fibrinous or serous pleurisy is but seldom 
fatal, unless some serious disease, such as pneumonia or 
tubercle, is behind it. Some think that it is liable to pass into 
an empyema if the serous effusion is copious, and not removed 
early; but while allowing this to be possible, I know noth- 
ing to support the view. As a rule, simple pleurisies clear 
up with great rapidity. The fluid in these cases is not often 
excessive. When there is excess of fluid it is more often 
than not already purulent. 

The prognosis in empyema is, however, more grave. 
Naturally, a chest full of pus must be a serious evil. If let 
alone, it tends to spoil the lung by chronic pressure and 
inflammation, or by burrowing into the lung. If it should 
make its way externally, the chances are better, but best of 
all are its early recognition and evacuation. Of late years 
this treatment has been very successful ; and in illustration 
thereof, I may say that in the last six-and-twenty consecu- 
tive cases under Dr. Frederick Taylor and myself, at the 
Evelina Hospital, there has only been one death, in a case 
of my own, where the child had suppurative pericarditis and 
peritonitis as well as empyema.* 

Treatment. — Fibrinous and serous pleurisy are best 
treated by opium in moderate doses to relieve the pain and 
the coucrh, and salines, such as the nitrate and citrate of 
potassium, or some effervescing saline, to act as a diuretic 
and diaphoretic. In the acute stages, warm fomentations 
are in most request; but cold compresses are also useful, 
changed every few minutes. In older children, the side 
should be firmly strapped, and warmth or cold can be ap- 

* Dr. Xewnham, who, as resident medical officer, has had the charge of all 
of them, tells me that twenty-three healed up entirely and are quite well ; 
in one a small sinus still remained ; one freely discharged for five weeks. 



PLEURISY, 3S5 

plied by means of compresses or the ice-pack outside the 
strapping. 

After the first few days, iodide of potassium, in one or two- 
grain doses, should be given with some syrup of the iodide of 
iron, the bowels being kept gently open by some mild ape- 
rient. It sometimes happens that although the general symp- 
toms clear up rapidly, the dulness remains behind ; but this is 
only to be expected when we consider the large amount of 
lymph which is sometimes found. It is best, under these 
circumstances, to apply counter-irritation externally by 
means of the liniment of iodine;* but more is probably to be 
gained by exercise and plenty of fresh air, by which it may 
be hoped to promote free expansion of the lungs. When 
the disease is acute and the effusion excessive, paracentesis 
may be advisable ; if so, it is probably better to draw off 
a moderate quantity than to aim at removing the whole. 
But I am no advocate for paracentesis merely because of the 
presence of fluid. There is evidence in abundance that 
serous effusions clear up rapidly by natural processes ; there 
is evidence in abundance, also, that the simple presence of 
fluid is not likely in childhood to harm the lung if the 
amount is not large and its duration be kept within a mod- 
erate limit of three or four weeks, and provided that the fluid 
shows signs of gradual diminution. When the effusion takes 
place rapidly, when it is in great excess, with displacement 
of heart, fever, pallor, and puffiness of the face, such are the 
symptoms which indicate the necessity for aspiration. 

We have next to deal with the treatment of empyema, 
and we shall be the better prepared to consider the question 

* Linimentum Iodi, Br. P., con: 

Iodine, . . . . . . 1 ^ ounce 

Iodide of Potassium, . . . . . ) 2 ounce 

Camphor, ....... ! 4 ounce 

Rectified Spirit, 10 fluid ounces. — Ed. 



386 THE DISEASES OF CHILDREN. 

in an\- individual case if we remember that the pleura, cavity 
is one which has difficulties and dangers all its own. The 

ility of the lung, the rigid nature of the thoracic wall, 
the nooks and crannies in which pus can form, all would 
seem to combine to make efficient treatment impossible. 
Yet it is remarkable — if only the one difficulty of inefficient 
drainage can be combated, and the cavity kept free from 
sepsis — how successful the treatment becomes. I have seen 
a pleural cavity six weeks after the evacuation of an em- 
pyema so perfectly obliterated by silky adhesions of connec- 
tive tissue, that, without the knowledge, one could not have 
believed that any disease could have existed of recent ye 

There are other less brilliant results, no doubt, and not 
infrequent, too. such as the persistence of a fistula and dis- 

gje, until the lung is spoiled, and the child dies ex- 
: aceous viscera ; but these are far less com- 
mon now than formerly, and will probably be even yet 
farther diminished in number as the frequency of empyema 
is recognized and its presence detected early. 

But now for the actual treatment. Having assured our- 
selves by exploration of the presence of pus, how is it to be 
treated? It maybe left alone, or it may be removed in one 
of several ways. 

I. The chest may be aspirated. 2. It may be tapped by 
trocar and canula, drawing off as much fluid as may be neces- 
sary, or as much as is possible. 3. After tapping, an india- 
rubber tube may be passed through the canula into the 
chest, and the canula being withdrawn, the tube remains as 
a siphon. 4. The old plan, and a very good one, may be 
adopted of making two openings in the chest, one above and 
one below, and passing a drainage-tube in at one and out at 
the other. 5. And. lastly, a free incision may be made. 
Each of these methods of removal has its advocates, and all 
are useful on occasion. But all my latest experience has 



PLEURISY. 



$«7 



gone to convince inc that, as a rule, a free incision in the 
seventh or eighth intercostal space — the position of the open- 
ing being mostly determined by the position of the pus — is 
an operation which is not attended by any serious risk, and, 
combined with free drainage afterwards, by means of as 
large an india-rubber tube as can be inserted, is very suc- 
cessful. 

I am inclined to insist less strongly than formerly on the 
position of the opening; it may be made wherever the ex- 
ploring needle indicates that the pus is easily reached, either 
in the front, side, or back of the chest. 

But it may not be always advisable in very young, deli- 
cate, or exhausted children, to open the chest thus. The 
incision is not altogether a trifle, and it may seem better 
every now and then either to aspirate or tap. 

In localized empyemas and those of rapid onset it may 
sometimes be advisable or necessary from surrounding cir- 
cumstances to aspirate the chest. Dr. Bowditch has had 
great success with simple aspiration. Dr. Thomas Barlow 
has also recorded good results, and I myself have had five 
cases in which nothing more than aspiration was required. 
This plan will find its most frequent application in very 
young children, and where the pus is in very small quantity. 

If the pus is in large quantity, it is of little use to try 
aspiration except as a preliminary to some more radical mea- 
sure ; and it is a fatal mistake to aspirate in such cases time 
after time, as is sometimes done. To do this is to take the 
surest means of converting the sac into a chronic abscess, 
and to invite a permanent fistula and collapse of the lung. 

The siphon plan is of use in such cases as where the 
materials necessary for incision on the antiseptic method 
are not ready to hand, or where, for other reasons, aspira- 
tion or incision are not judged to be the best operations for 
the case. It is also of use when, owing to extreme disten- 



388 THE DISEASES OF CHILDREN. 

sion of the cavity and displacement of the viscera, the rapid 
evacuation of the pus by incision seems to threaten some 
risk. The two openings and a connecting drainage-tube 
offer some advantages when there is a difficulty in thor- 
oughly draining the chest. And in such cases where the 
empyema points spontaneously, it may perhaps be left 
alone or opened at the spot towards which the pus is tend- 
ing. In private practice it will often happen, from various 
circumstances, that the treatment has to be modified to suit 
those circumstances — in other words, we are not always 
able to act up to the most modern light as regards a sur- 
gical operation, and I have sometimes been compelled to 
advise tapping with a large trocar, and leaving a simple 
tube in the opening thus made. This is not a plan that is 
to be recommended ; but, under strict antiseptic precautions, 
it may be completely successful. The siphon plan alluded 
to above requires a soft india-rubber tube of some length. 
One end of this is passed into the chest, and the other lies 
in a vessel containing some antiseptic fluid, such as weak 
carbolic lotion. It is convenient to divide it in the centre, 
and connect the divided ends by a piece of glass tubing ; in 
this way the perfect action of the siphon is readily gauged. 
This plan has no doubt some not unimportant advantages 
over some others : the operation is easy of performance ; it 
is not a very painful one ; it is convenient if the chest re- 
quires washing out; and, if all goes well, the chest is kept 
sweet. But empyema in children is very liable to be accom- 
panied by large flakes of lymph in the cavity, and the tube 
becomes blocked and has to be removed, so that incision 
is to be preferred as giving a freer exit to such material. 

Next, one or two points with reference to the operation 
of incision. If the chest is very full indeed, the operation 
may be followed by severe suffocative dyspnoea. Taking 
away a quantity of fluid somewhat suddenly must of neces- 



PLEURISY. 389 

sity disturb the intra-thoracic circulation, which has in 
many cases become accommodated to the abnormal state, 
and a risk is run thereby of the occurrence of a sudden 
oedema of the sound lung, which has not so very rarely 
proved rapidly fatal. Therefore, in cases of extreme effu- 
sion, it may be advisable to make a preliminary aspiration 
before draining the chest thoroughly ; or, if incision be 
decided upon, the pus should be allowed to drain away 
slowly for the first few hours. Its rate of exit can easily be 
regulated, for the ribs are so close together, in any case, that 
the difficulty lies in obtaining a sufficiently free outlet by 
whatever means may be adopted. 

During the operation great care should be exercised to 
insure that the opening between the ribs is as free as pos- 
sible : and both then and for the first day or two during the 
dressings every facility should be afforded for the escape of 
the masses of fibrinous coagulum so commonly present. 
This is best done by opening the aperture by forceps, while 
the drainage-tube is withdrawn, and extracting anything 
that may be within reach. Except in this way, the chest 
cavity is to be meddled with as little as possible ; and all 
washing out, though, unfortunately, it must be resorted 
to occasionally if the cavity becomes foul, is to be depre- 
cated. 

Washing out the pleura is as difficult of efficient accom- 
plishment as washing out the bladder. In either case sepsis 
must be prevented. When once the cavity has become foul 
there is small chance of restorative action by any such means. 
Moreover, it is not without risk ; it may lead to sudden 
death. A number of cases have of late years been placed 
on record in which a sudden comatose state culminating in 
death has come to patients while having their pleura irri- 
gated. The cause of such a calamity is in much obscurity 
— by some it is considered to be embolic, by others to be 

33 



390 THE DISEASES OF CHILDREN. 

due to some reflex nerve-storm due to interference with the 
pneumogastric ; but the facts are quite certain, and they 
must be the mainsprings of our action or inaction. Next, 
the drainage-tube is to be dispensed with as soon as possi- 
ble. Inefficient drainage is, no doubt, the cause of many a 
bad result, but it is equally true that many a case becomes 
intractable from the too prolonged use of drainage-tubes. 
After the pus has been removed, the auscultatory signs show 
conclusively in most cases that the compressed lung soon 
begins to do a considerable amount of work. Vesicular 
breathing may often be heard to within a very short distance 
of the aperture in the chest-wall ; add to this some ascent 
of the diaphragm and some falling-in of the chest-wall, 
which is generally quite a noticeable feature of such cases, 
and it is obvious that the cavity soon becomes much reduced 
in size. A probe or a considerable length of drainage-tube 
can no doubt be inserted, but this proves nothing as to the 
existence of a large cavity. The instruments make a pas- 
sage for themselves in the as yet unconsolidated lymph. 

In operating a free incision is made between the ribs, large 
enough linearly to allow of the passage of the finger into 
the cavity, should the space between the ribs permit it. 
This is free enough to allow of the introduction of a large 
drainage-tube and something over, and thus, to all intents, a 
double opening into the chest is secured. After removing 
some of the pus and any masses of lymph that may be within 
reach, some four or five inches of a freely perforated, stout, 
but soft, red india-rubber drainage-tube which has been 
well soaked in carbolic acid is then passed into the chest, 
and secured in position, and the usual antiseptic protectives, 
as advised by Professor Lister, are placed over all. The 
dressings should be removed twice in the first twenty-four 
hours, and once daily for the first few days afterwards, and 
the drainage-tube in the chest is to be daily shortened, so 



PLEURISY. 39I 

that at the end of five or six days only an inch or an inch 
and a half remains. This is length enough for keeping the 
external aperture patent, and the internal parts are no longer 
interfered with. If the discharge remains very slight, the 
tube can be removed altogether, the temperature being 
watched closely : so that, if after its removal any evening 
rise occurs, it may be at once re-inserted. It not unfre- 
quently happens that with early removal such as this it 
becomes necessary to re-insert the tube for a time, but this 
is a less evil than its prolonged use — indeed, no additional 
evil at all, if the temperature be taken as a guide. This will 
give sufficiently early notice to prevent any accumulation. 
Next, a word as to Listerism — it should always be adopted 
in the first two or three weeks. Practically it is continued 
at the Evelina Hospital till the child leaves, and that may 
not be for some weeks ; but I believe that its continued 
application is sometimes harmful in keeping small cavities 
open. Therefore, when there is but a small cavity remain- 
ing, it is better to send the child to the purest possible air, 
and apply nothing but a little marine wool, which should 
be frequently changed. 

It is not advisable to keep such cases too long in bed ; a 
week or ten days after the empyema has been opened they 
may sit up, and even sit out in the open air if possible. 

Last, and most important of all — unfortunately for hos- 
pital patients a treatment that cannot often be utilized — comes 
Margate air. Any seaside air is beneficial, but, weather and 
season permitting, I do not believe there is any corner of 
England so quickly restorative to children with empyema as 
that in which Margate and Broadstairs are situated ; and, 
personally, I set more store by a change of this kind after 
the first three or four weeks have passed than in any con- 
tinuation of antiseptic dressings. 

This is, I believe, in short, the best that can be done for 



39 2 THE DISEASES OF CHILDREN. 

such cases. But we must bear in mind that the conditions 
are such as to present obstacles in many cases to successful 
treatment, and empyema must therefore always be liable to 
prove disappointing. If we have to deal with an abscess in 
most other parts the pus can be entirely evacuated, and the 
walls of the cavity can be adapted to each other and kept in 
position. In the chest it is not so ; we are dependent upon 
contraction of the chest-wall, ascent of the diaphragm, granu- 
lation from the pleura, and expansion of the lung; and it is 
hardly to be expected that repair conducted under such 
adverse circumstances should present no difficulties ; we 
should the rather expect that the cavity is more likely to 
be diminished in some directions, obliterated in some, and 
so cut up irregularly as to render complete drainage a mat- 
ter of great difficulty; and so it too frequently is. But, 
nevertheless, it can be said that, recognized early and treated 
secundum artem, the treatment of empyema, from being one 
of the most disheartening, has become one of the most suc- 
cessful and gratifying of surgical operations. 

Of late, finding that the results of the treatment of em- 
pyema have not quite come up to their expectations, some 
have advocated the excision of a portion of one or more 
ribs, with the object of facilitating the falling in of the chest 
and of obtaining more free drainage. Applied to the ma- 
jority of cases the practice is unnecessary, and therefore bad. 
The treatment of empyema by incision, as I have just said, 
is as successful as it can reasonably be expected to be, if the 
cases are taken in good time; and in cases which have been 
long overlooked, or which have been long discharging, what- 
ever we may do is, in the majority of instances, unavailing. 
The large aperture that is made by the removal of the rib 
quickly closes up, and we are no better off than before. 



ACUTE TUBERCULOSIS. 393 



CHAPTER XXV. 

ACUTE TUBERCULOSIS. 

Acute Tuberculosis has of necessity been several times 
touched upon in connection with the different viscera which 
the disease more particulary affects; nevertheless, it is such 
a distinct disease, and has so definite a clinical position, that 
a few words may be devoted to its more general bearings. 
It is a disease confined to no age, but is particularly one of 
childhood. 

Pathology. — But little is known of its nature at present, 
although of late years several very interesting observations 
have been made, which, if they ultimately take rank as as- 
sured facts, are of the greatest importance. First of these 
maybe mentioned the discovery of the bacillus tubercu- 
losis. This small body is supposed to be the virus which, 
introduced from without, forms a nidus in some of the lym- 
phatic structures, provokes caseation, and thence, by fertiliz- 
ing, becomes disseminated in all parts of the body. Certain 
experiments, too, have of late been carried out, which go to 
show that tubercle is propagated by inoculation only when 
the bacillus forms part of the virus which is introduced, in 
contradiction to previous less rigid experiments, which 
pointed to the probability of any suppurative focus being 
sufficient for the purpose. Next, there is a disease well 
known amongst cattle, which, having much of the anatom- 
ical distribution and histological structure of tubercle, is 
capable of transmission from the diseased animal to the 
healthy by means of the milk from diseased cows. Other 



ig6 THE DISEASES OF CHILDREN. 

culosis, for jaundice is not common at this age. It, and the 
enlargement of the liver and spleen, with evidences of ema- 
ciation and disturbed respiration, suggested tubercular dis- 
ease of the liver and general tuberculosis. Even now the 
opinion was not altogether an unwavering one, for the jaun- 
dice disappeared and the child improved and left his bed for 
a day or two. Then he had a relapse, and his temperature 
ran up to 104°, and he died seven weeks after admission. 
The most that his chest had revealed was a good deal of 
dry crackling, chiefly below the nipples and in the scapular 
region, and occasional moist sounds in other parts. Dulness 
also came and went in an irregular fashion. At the autopsy, 
however, the lungs were stuffed with tubercle, and the bron- 
chial glands were caseous and softening. In the liver were 
many small nodules of bile-stained tubercle, such as have 
been ascribed to tuberculosis of the ducts. The spleen also 
contained many tubercles. 

Diagnosis. — As I have already said, this is often difficult 
or impossible ; but inasmuch as it is a general disease, affect- 
ing all the viscera and serous membranes, some help may 
sometimes be gained by detecting a slight pleuritic rub here 
or there, or any evidence of consolidation about the roots 
of the lungs. Hyperesthesia of the skin and muscular 
twitchings not uncommonly indicate tubercular formation 
in the spinal membranes, and any intolerance of light should 
be carefully considered. Any tubercle in the choroid or 
changes in the fundus oculi would make things certain. It 
may be added, that a hard enlargement of the spleen may 
give occasional help, but we must remember that the en- 
larged spleen of typhoid fever is sometimes, in childhood, an 
unusually resistant one, and the disease is most likely to be 
overlooked or to be mistaken for typhoid fever. 

Prognosis. — It runs a somewhat variable course, from 
three to six weeks ; but, so far as is known, is always fatal. 



ACUTE TUBERCULOSIS. 



397 



Treatment. — Of late years, one has indulged the hope 
that some drug might be found to arrest the growth of the 
nodules of tubercle; but iodide of potassium, quinine, per- 
chloride of mercury, salicylic acid, iodoform, turpentine, etc., 
have all been tried, and, as regards general tuberculosis at 
any rate, have been found wanting, and one cannot say that 
there is any recognized treatment. 



34 



39§ THE DISEASES OF CHILDREN. 



CHAPTER XXVI. 

SCROFULA— LEUKEMIA— BRONCHIAL PHTHISIS. 

Diseases of the Lymphatic Glands. — Under this heading 
come diseases of the mediastinal and abdominal glands and 
other less-known conditions. The more common affections 
are : Caseous disease of the mediastinal glands, or bron- 
chial phthisis; Tabes mesenterica, or abdominal phthisis; 
Caseous disease of the more superficial glands, or scrofula. 
To diseases of this kind also belong the various fleshy or 
lympho-sarcomatous growths, general or local, infiltrating 
or not infiltrating, as the case may be. Of this latter group, 
the complex of symptoms called Hodgkin's disease, or 
lymphatic leukaemia, forms a part. And the leucocythaemic 
condition may be conveniently considered in the same con- 
nection. 

I shall probably treat the subject most intelligibly if I 
first, in a general way, describe the different varieties of 
cases which come under notice before taking the local con- 
ditions seriatim. 

Starting thus from the simplest form of lymphatic hyper- 
plasia, and proceeding to the more complex, we may notice, 
first, the case of the child of six or eight years old, good- 
looking, or perhaps with the thick skin and irregular fea- 
tures supposed to denote scrofula, with chronic enlargement 
of the tonsils. The tonsils repeatedly inflame, and as often 
as they are examined, they show cheesy secretions filling 
their follicles and exuding from them upon pressure. By- 
and-by the glands in the neck at the angle of the jaw begin 
to enlarge ; in one case, to suppurate quickly and subside 



SCROFULA LEUKEMIA BRONCHIAL PHTHISIS. 399 

again ; in another, to undergo a more slow process of en- 
largement, followed by caseation and slow ulceration which 
produces that scarring of the neck so often seen ; in another, 
to gradually develop into a huge localized tumor, with some 
caseation in parts, but in which the most noticeable feature 
is slow and continuous growth. In another class of cases, 
the local glandular enlargement slowly extends to other 
glands in the neighborhood, then perhaps stops awhile, and 
then again extends, and so on, with fitful course. The 
glands on the opposite side become infected, still all caseat- 
ing as they enlarge, and the enlargement not being of any 
great .extent. Slowly the disease extends over the body, 
the child presenting an oscillating pyrexia, and gradually 
emaciating, till death comes by tuberculosis, or some disease 
of like character breaks out elsewhere — a spinal caries, a 
multiple epiphysitis, with caseous abscesses in the bones, 
and the chronic exhaustion of suppuration, lardaceous dis- 
ease, or nephritis. 

These are the cases called scrofulous. The picture of a 
child is now before me, with her fair hair, red eyelids, ulcerated 
and bloodshot eye, her thick lips, spongy gums, offensive 
breath, and hard and dry skin. Unhealthy sores form on 
her skin, and the neighboring lymphatic glands enlarge, and 
although the sores slowly heal, the glands continue to in- 
crease ; others become affected, and, witli a hectic fever, she 
slowly emaciates, without the least amelioration by good 
living or drugs. What the end of such a case may be it is 
hard to tell ; it may be acute tuberculosis, a more chronic 
phthisis, bone disease, or scrofulous kidney. Examples in 
any number of all these varieties, and others intermediate 
lie thick along the practice of every medical man. Happily, 
too, few are unfamiliar with exceptions where the scrofulous 
condition, even in its worst phases, •sometimes strangely 



THE DISEASES OF CHILDREN. 

stops — perhaps for good, perhaps, alas ! to light up again 
suddenly in later years. 

There is yet another group of cases ; that in which growth 

replaces inflammation. The commencement of such is much 
the same. A local tumor of fleshy consistence slowly arises 
in the glands — most often in the neck, may be in one axilla, 
more rarely in the groin. At first we think we have tc 
with the ordinary hyperplastic and caseating gland, and not 
unlikely some carious tooth may seem to start it ; but it goes 
on increasing, until at last a huge growth is formed, which 
buries the structures of the neck and chokes the patient. I 
have seen several cases of this kind. I give a note of one, 
because it was carefully watched for some time by Dr. Dukes, 
of Rugby. It was that of a girl of ten She had always 
lived at Rugby, and about six months before I saw her she 
had had dropsy following scarlatina. The glands in the 
neck became swollen three or four moi ter, commenc- 

ing on the left side. A lump in the right axilla was no: 
about the same time. The swelling of the glands in the 
neck gradually increased until it formed a nodulated elastic 

ling, which uniformly distended both sides of the neck. 
The pulse was very rapid, and there was a short systolic 

: bruit, but no other disease was evident. The lungs, 
the mediastinum, the liver, spleen, and blood were all 
normal. Dr. Dukes tried all manner oi drugs, but without 
success, and the child died eighteen months to two years 

wards of characteristic Hodgkin's disease, with general 
enlargement of all the lymphatic glands, though with but 
slight enlargement of the spleen. The submaxillar}' en- 
largement was so great as to obstruct the breathing. She 

much wasted and extremely anaemic. 
In another case - kind, a seven, a mass 

ids had been removed from the neck twelve months 
before ; but glandular masses still existed on both sides of 



SCROFULA — LKUK.EMIA BRONCHIAL PHTHISIS. J.OI 

the neck and in the left axilla. There was also some evi- 
dence of pressure on the right bronchus. The liver reached 
nearly to the umbilicus, and the spleen was large and firm. 
There was no excess of leucocytes in the blood. 

Here then are local tumors which correspond with the 
local inflammation ; two divergent results of local stimula- 
tion. But further than this, in the enlargement of the glands 
in one axilla, we see how liable the local disease is to be- 
come more generalized, and in the most advanced cases we 
see the glands rapidly enlarge all over the body ; the spleen, 
liver, and kidneys undergo characteristic changes, the fundus 
occuli exhibits a form of hemorrhagic retinitis, the body 
wastes, the child becomes anaemic, there is hectic fever, 
simulating that from the formation of pus, and death results 
from epistaxis, bleeding from the gums, purpura, albuminuria, 
exhaustion, or some leukaemic form of pneumonia. But 
even this does not complete the chain of conditions. In 
these, the more common cases, the hyperplasia of the glands, 
although generalized, is still confined to the glands; but 
occasionally this is not so, and the generalized gland dis- 
ease oversteps its boundaries, and spreads into other tissues. 
Dr. Frederick Taylor has published a case of this nature in 
a boy aged twelve, who had leucocythaemia, hypertrophy of 
the spleen and lymphatic glands, and fleshy lymphadeno- 
matous growths of the pleura, mediastinum, liver, kidneys, 
and epididymis. This child had a high temperature and 
purpura, and died with dropsy, scant}* urine, labored breath- 
ing, and ulcerated gums. 

This case may, indeed, be regarded as typical in another 
way — viz., that the boy not only suffered from enlarged 
spleen, but he also had leucocythaemia. Some pathologists 
are inclined to regard the lymphatic leukaemia in which 
there is no increase of white blood-cells in the blood as 
absolutely distinct from the splenic form of disease, in which 



402 THE DISEASES OF CHILDREN. 

that is the most characteristic phenomenon ; but there is no 
doubt that cases such as this are occasionally met with in 
which the two forms of disease are combined. 

Now all these grades of lymphatic disease, inflammatory 
and hyperplastic, we may dissociate if we will, and consider 
singly. For instance, we may take the slow caseation of the 
glands, local or general, and calling it scrofula, disown its 
relations with syphilis, with rickets, with any other form of 
malnutrition ; but my point is this, that studying the diseases 
of lymphatic tissues, not only does this particular disease 
exist, but that such a one is necessary to make the scheme 
of these diseases complete, and in accord with the changes 
that go on in other tissues. Pathology, therefore, seems 
to me to teach that scrofula is, so to speak, a normal 
process of decay in lymphatic glands : one that is to be ex- 
pected as an occasional thing under any circumstances of 
life, and, therefore, that will certainly be aggravated by all 
causes of malnutrition — syphilitic, rachitic, or whatever they 
may be. In the same way with the fleshy hypertrophies or 
growths. We may, if it be convenient, take any one of the 
more common examples I have given, and give it a name — 
Hodgkin's disease, for example, where the lymphatic glands 
are large, fleshy, caseating, but not softening; where the 
spleen is like hardbake, from the yellow nodules it contains, 
and the liver and kidneys are diseased by an infiltrating 
lymphomatous growth. But the student will only be puzzled 
if he attempts to keep to any arbitrary lines. There is a 
process of growth in the lymphatic tissues just as there is 
one for the skin in the way of papilloma and epithelioma; 
it is only a question of more or less ; and all the conditions 
I have described form one series, the individual elements of 
which are apt to combine. 

I hope in thus attempting to make a disease which is 
puzzling to the student somewhat clearer from a pathological 



SCROFULA LEUKEMIA — BRONCHIAL PHTHISIS. 4O3 

standpoint, I shall not be considered to have made confu- 
sion worse, more particularly as, except in regard to special 
symptoms and treatment, it seems unnecessary to say much 
here of some grades of this series. Such as do not admit of 
being thus dismissed now follow : 

Scrofula. — From what has been already said, it will have 
been learnt that cheesy enlargement of glands, unhealthy 
ulcerations of the skin and mucous membrane, and cheesy 
inflammation of bones and joints, are the characteristics of 
this disease. 

Some hold that it is due to a constitutional condition ; 
others that it is the result of local disease ; but, however 
this may be, the clinical course of too many cases undoubt- 
edly seems to show that the disease does spread from one 
part to another, and the risks attaching to it are based upon 
that clinical fact. The* treatment of such cases will vary 
according as we hold the constitutional or the local element 
to be the more important; but, given a case of cheesy en- 
largement of the glands of the neck, for example, one can- 
not but think, in prospecting the future of the child, that its 
risks lie in the local disease becoming generalized in some 
way by a process of infection ; or, to take the other view, by 
the constitutional something, of which we here see the local 
expression, breaking out in some more general manner. 

I put these two views thus pointedly for the purpose of 
discussing the treatment. Those who hold that the disease 
is a constitutional one treat it by general means — such as 
seaside air, well-ventilated living rooms, plenty of exercise ; 
and, internally, good food, cod-liver oil, iodide of iron, and 
tonics of all kinds. It is usually advised that any local 
irritation should be looked to, particularly enlarged tonsils 
and decayed teeth, and various remedies have been sug- 
gested for acting upon the diseased glands. Chief of these 
are sulphide of calcium, phosphorus, chloride of calcium, 



404 THE DISEASES OF CHILDREN. 

and bicarbonate of sodium. The glands may be stimulated 
locally by iodine, and the child maybe made to inhale iodine 
by keeping some crystals in a perforated pill-box in the 
rooms which it inhabits. When one looks back over a long 
series of years, one cannot but admit that this plan of treat- 
ment has been in many cases successful — how often it fails 
there is but little opportunity of knowing — but in the im- 
mediate present it is far otherwise, and such cases may go 
on week after week without improvement until they are ulti- 
mately lost sight of. One is not therefore surprised that, 
with the doctrines of local infection, which have been advo- 
cated of late years with much persistency, attempts have 
been made to cut the knot of medical powerlessness by an 
appeal to surgical aid, and chronic and intractable enlarge- 
ments of glands are now frequently removed by the knife. 
There is one practical hindrance to 'the more general adop- 
tion of this method — viz., that these gland swellings are so 
common and have so long been treated by less caustic 
methods that their nature is never regarded in its more 
serious aspects, and radical suggestions of this sort are often 
received with surprise and repudiation. Other means less 
severe are practiced by many surgeons, and I may mention 
the local galvanic caustic suggested by my colleague, Mr. 
Golding Bird, as being at once ingenious and useful to 
hasten the softening down and discharge of these caseous 
masses. These, however, are the two methods. The time 
is hardly yet come for a decision upon the value of the new 
method ; but, so far, it seems to me to be less satisfactory 
than the other. For, while the ordeal to be gone through 
in the way of operation is no slight one, the glandular masses 
have in several instances reformed within a short time of the 
operation. For the present, therefore, it seems wiser to 
keep on the old paths, and in the worst cases — certainly in 
the more localized swellings — where possible to insist upon 



SCROFULA — LEUK.EMIA — BRONCHIAL PHTHISIS. 405 

residence at such places as Margate, Woodhall, Droitwich, 
Kreuznach, Soden, or others, as the first necessity, and then 
to practice all those other measures of general hygiene to 
which I have alluded. 

For the fleshy gland tumors, a resort to extirpation is 
more necessary, and should be proposed in young people 
when the growth is steady and threatening to become un- 
manageable. It is too late to do anything when the disease 
has extended to both sides of the neck. The glands must 
be removed when of moderate size, if treated in this way 
at all. 

Of the treatment of the more generalized growths and of 
leucocythaemia, I need hardly speak ; for, although many 
things have been tried, nothing has proved efficacious. In 
leucocythaemia, with enlargement of the spleen, it is worth 
remark that it has originated after malarial poisoning in a 
fair proportion of adult cases. 

Chronic enlargement of the spleen is not uncommon in 
childhood in several diseases, one of which is ague. It will 
be well, therefore, to keep a watch on all such cases. Pos- 
sibly, by so doing, leucocythaemia may in some instances 
be averted or arrested. 

Bronchial Phthisis. — By this is meant cheesy enlarge- 
ment, softening, or calcareous change in the glands of the 
mediastinum, whether anterior or posterior, but chiefly the 
latter, and the associated changes, if any, with which it may 
be accompanied in the lung. 

It has received from some authors a distinct name for two 
reasons — first, because some consider it may give rise to a 
special group of symptoms ; and, secondly, because the 
pattern of the disease in the lung is often characteristic. 

The existence of large and caseous glands in the medias- 
tinum is very common. Rilliet and Barthez say it occurs 
in 79 per cent, of all cases of phthisis in children. Indeed, 



4<j6 the diseases of children. 

this is the weak point of its specialty, for it certainly is of 
more frequent occurrence without any special symptoms 
than with them, and no doubt in many cases of this and of 
pulmonary phthisis nothing peculiar in the distribution of 
the latter disease can be demonstrated. But perhaps this 
difficulty in part arises from a want of consideration of the 
fact that bronchial phthisis maybe either primary or second- 
ary. Sometimes the caseous disease of the glands is the 
primary disease, and the phthisis is a subsequent develop- 
ment ; in others, it is the direct result of the pulmonary 
tuberculosis. There can be no doubt that caseous disease 
of the bronchial glands precedes any tubercular disease of 
the lung in an appreciable number of cases, and there can, 
I think also, be no doubt, from the observations of numerous 
writers both at home and abroad, that such enlargement is 
occasionally attended with peculiar and characteristic symp- 
toms. 

Inflammation of the bronchial glands can be traced in all 
its stages in the post-mortem room with great ease from the 
frequency with which it occurs. We find the acutely 
inflamed or swollen pink soft gland ; we find the gray, 
swollen, more fleshy state of a later stage ; we see sometimes 
the glands studded with gray miliary tubercular grains ; we 
see at others one part of the gland thus tubercular, another 
cheesy, and another, perhaps, acutely inflamed. It is quite 
common to see an old cheesy deposit in a gland, and fresh 
tubercle extending from its borders. We may see, again, 
the glands shrivelled into calcareous masses, with more or 
less fibrous matting of the parts about them, and sometimes 
with definite adhesions to the pneumogastric or its branches. 
We may find evidence that they have ulcerated into the 
oesophagus or bronchus ; and as regards the lungs and adja- 
cent parts, miliary tubercle may spread from them to the 
adjacent pleura or pericardium; or, as is more common, the 



SCROFULA LEUKAEMIA BRONCHIAL PHTHISIS. 407 

lung is infiltrated on one side or both with cheesy or miliary 
tubercle, which, leading to solidification chiefly about the 
root, disseminates a miliary tuberculosis into the lung far 
and wide, by means of the bronchial septa. The glands may 
be much enlarged, and extend up into the neck along the 
sides of the trachea. They do not often lead to compres- 
sion of the neighboring canals, either respiratory or circula- 
tory ; but they tend to soften, to lead to mediastinal abscess, 
or, more commonly, to ulceration into the bronchus or 
oesophagus. It is thus that calcareous masses come to be 
expectorated, and that evidences of bygone disease are not 
unfrequently found in the post-mortem room. Thus it is 
that occasionally a child is suddenly choked by the entrance 
of a softened gland into the trachea by perforation of the 
tube. 

The disease in the glands is usually associated with pul- 
monary tuberculosis, and not rarely with the condition I 
have called cheesy consolidation (p. 364). This change is 
apparently allied to that which has been denominated by 
Dr. Gee, " The chronic pneumonia which attends disease of 
the tracheal and bronchial glands.''* 

The conditions under which disease of the glands is likely 
to be present are such as pertain to cheesy glands in general 
so far as any constitutional element predisposes to it ; but, 
locally, all the conditions of catarrhal inflammation of the 
trachea, bronchus, and lung, are the immediate cause, and 
thus whooping-cough, measles, rachitis, as causes of collapse, 
etc., are its most common precursors. 

Symptoms. — These have already been in a measure de- 
tailed under the head of reflex spasm, the chapter on which 
(p. 308) may be referred to. But in addition to the symp- 
toms due to spasm, there are others which may be present 

* " St. Barth. Hosp. Rep.," vol. xiii. 



408 THE DISEASES OF CHILDREN. 

due to pressure of the enlarged glands upon the adjacent 
structures ; such are, occasional difficulty of swallowing, and 
puffiness or oedema of the face or parts about the neck. 
Haemoptysis may occur, but its interpretation would be 
equivocal. 

As regards physical signs, dulness between the scapulae 
is rightly considered the most reliable ; it should always be 
carefully searched for over the fourth or fifth dorsal vertebra 
between the scapulae, and comparison made of the space on 
each side of the spine. If the glands are large, some dul- 
ness may reasonably be expected. The manubrium sterni 
and the parts on either side of it should also be examined, 
for although disease in the anterior mediastinum is much 
more rare, it is now and then present and dulness can be 
detected. A comparison of the breathing on the two sides 
often also adds much to our information, some difference on 
the one side or the other being detected — in the way of 
bronchial breathing, bronchophony, or even crepitation — 
or some deficiency or harshness of respiration being dis- 
cerned on one side or the other. 

Dr. Eustace Smith calls attention to the occasional exist- 
ence of a venous hum in these cases, due to the pressure of 
the glands upon the innominate vein. It may be best pro- 
duced by bending the head backwards, so that the face is 
horizontal and looking to the ceiling. 

The general symptoms of phthisis, wasting and hectic, are 
so frequently part of the clinical picture, that they also must 
be considered to be symptoms of the special disease. 

Diagnosis. — Such cases often escape notice by reason of 
want of care in seeking for them. The most powerful means 
for their detection is the ever-present memory of the fre- 
quency of their occurrence. But it must also be remembered 
that the symptoms of spasm may be very intense, and the 
disease under such circumstances may be mistaken for 



SCROFULA LEUK7EMIA BRONCHIAL PHTHISIS. 4O9 

spasmodic asthma, or even for some local laryngeal disease. 
Intra-thoracic tumors, though not common in childhood, 
might possibly on an occasion mislead us. 

Prognosis. — This is always grave. The disease is too 
fertile a source of pulmonary tuberculosis to allow anything 
but fear for the result when once the existence of enlarged 
glands has been positively determined. But the general 
appearance, the existence of progressive emaciation, of 
pyrexia, and so on, must be taken into account. If the child 
is gaining flesh, not feverish at night, or showing other signs 
of ill-health, there is no reason for being over-anxious; for 
if the post-mortem room gives too abundant evidences of the 
risk, it gives much evidence also of the tendency to cure of 
these caseous glands. 

The treatment has already been given at p. 312. It con- 
sists of sending the child to the seaside, and keeping it there ; 
giving it good digestible food, and seeing that it digests 
what it eats ; and administering iron, iodine, cod-liver oil, 
etc., internally. 



. 



410 THE DISEASES OF CHILDREN. 



CHAPTER XXVII. 

TABES MESENTERICA AND TUBERCULAR PERITONITIS. 

Abdominal Tubercle is found under two or three varie- 
ties — Tabes Mesenterica, Tubercular Peritonitis, and an in- 
termediate condition, not well separable from either, in 
which a layer — sometimes of considerable thickness — forms 
upon the surface of the serous membrane, sometimes be- 
tween diaphragm and liver, sometimes in the omentum, or 
upon the surface of the intestines uniting it with the ab- 
dominal wall. All these conditions are often more or less 
combined. 

Tabes Mesenterica (caseous or tubercular disease of the 
mesenteric glands) is not uncommon ; nevertheless, it is 
rare indeed in comparison with the " consumption of the 
bowels " which is so often heard of in the dwellings of the 
poor. From a large out-patient department at the Evelina 
Hospital, during several years, and when at least 6000 or 
7000 children must have come under observation, and pro- 
bably considerably more, I have only notes of forty-six 
cases, and half of these were but of doubtful nature. Some 
few others are to be found associated with phthisis, but as a 
substantive ailment we might have supposed it to be more 
common than it is. Many diseases simulate it for a time. 
A child wastes and the stomach enlarges as a result of 
chronic indigestion from unwholesome food, uncleanliness, 
and bad air. It wastes because it is starved, and the stomach 
grows large, or apparently so, from flatulence combined with 
a tendency to contraction of the lungs and collapse which 
exists in feeble children. No doubt, too, in these conditions 






TABES MESENTERICA AND TUBERCULAR PERITONITIS. 41 I 

is laid the commencement of many a true case of tabes 
mesenterica, but it is unsafe to draw any conclusion upon 
the nature of the disease until such time as a child has been 
subjected to prolonged watching and careful treatment. 
Hundreds of cases like this get rapidly well under proper 
attention, while it is the tens only, or even the units, which 
have tubercular disease of the mesenteric glands. 

Symptoms. — These are indefinite ; wasting, increase in 
size of the abdomen, abdominal pain and griping after food, 
followed by diarrhoea, are the principal. On a more minute 
examination the nightly temperature is febrile. But it is 
not uncommon in making inspections to find early, and 
sometimes moderately advanced, cheesy swelling of the 
glands which had not been suspected, and where, therefore, 
it must be supposed they had given no indication of their 
presence. In later cases there is some superadded ulcera- 
tion of the bowels which may be the cause of the diarrhoea ; 
sometimes tubercular peritonitis, which explains the pain. 
The abdominal wall is often natural, or, if swollen, soft and 
easily depressed ; occasionally it is even retracted, so that it 
is very difficult indeed to say what are certainly the symp- 
toms of uncomplicated tabes mesenterica. The only certain 
indication is the detection of the glands themselves by palpa- 
tion through the abdominal wall. But even here it has 
always seemed to me that this sign is of little value when 
it is most wanted, viz., in cases of early disease. However, 
it must be looked for in all cases by careful palpation round 
the umbilicus, by pressing backwards towards the spine, and 
also by manipulating the abdominal wall between the two 
hands from side to side. The possibility of the detection of 
the glands, unless they be of very large size, will depend a 
good deal upon the state of the intestines. If the bowels 
be much distended with gas, they will be overlooked. 
Therefore repeated examinations must be made, and in 



412 THE DISEASES OF CHILDREN. 

cases of doubt an enema should be administered and the 
examination conducted shortly after its action. In advanced 
cases the mass is large, the body thin, the intestines often 
retracted, and then there will be no difficulty in detecting 
the disease ; but these are cases in which the general features 
of the case have already left little doubt. Moreover, in 
these cases what appears to be a mass of glands may event- 
ually turn out to be not so much glandular as due to coils 
of matted intestine. 

In advanced cases other conditions arise which help 
towards the diagnosis, if any help be needed ; the cheesy 
glands infect the peritoneum in their neighborhood, and 
adhesions occur between the intestinal coils, and between 
them and the abdominal wall. It is then that irregular dis- 
tension of the abdomen is liable to occur, and much intes- 
tinal gurgling and rumbling, as in chronic stricture in the 
adult. Sometimes the tubercular disease spreads from the 
hypogastric region upwards to the umbilicus, when a hard 
indurated cord or ring is felt around the umbilicus, and a 
faecal fistula may form. Sometimes a general tubercular 
peritonitis arises with ascites. In these cases the fever is 
considerable, and the pain also, and the course of the dis- 
ease tends to be rapid. Softening of the glands is only 
occasional. It occurs now and then, and either leads to 
ulceration into the intestines, or to localized abscesses 
amongst the intestinal coils. Hitherto I have avoided 
reference to the state of the mucous membrane of the 
bowel, because the subject is a difficult one. Most authors 
treat of tabes, and rightly so, as a primary disease, and ul- 
ceration of the bowel as a complication. But, as a matter 
of fact, the two are so constantly associated that it is impos- 
sible to separate them, and it may almost be said that the 
presence of the one compels the existence of the other. It 
may be quite true, as I have said, that calcified glands may 



TABES MESENTERICA AND TUBERCULAR PERITONITIS. 413 

be found in the mesentery without any definite evidence of 
former intestinal ulceration. Nevertheless, it is exceedingly 
rare in any case of recent disease to find the intestine abso- 
lutely free from ulceration, and hence it is that it is so diffi- 
cult to say which is the more common mode of commence- 
ment — by ulceration of the intestine or by disease of the 
glands — for in any case swollen yellow, enlarged solitary 
glands are likely to be found in various parts of the small 
intestine, some of them ulcerated, and showing raised 
yellowish edges with vascularization of the mucous mem- 
brane around them, or else large irregular thick-edged 
chronic ulcers. These have tubercular granules on their 
peritoneal aspect, and often adhesions and communications 
between one coil and another, such as make a complete ex- 
amination of the intestine impossible. 

The severity of the diarrhoea will in a measure, though 
not altogether, depend upon the extent of the ulceration. 
The motions passed in these cases are usually liquid, dark 
brown, and offensive. They sometimes, but not often, con- 
tain small coagula of blood. 

The pain which some children suffer in advanced cases is 
sometimes very distressing. It seems to be of a severe 
griping character, which by its frequent recurrence, keeps 
them in perpetual misery. 

Morbid Anatomy. — It hardly seems necessary to say 
more than has been said already upon tabes mesenterica. I 
should,. how r ever, emphasize two points (i) that calcareous 
glands are not uncommon in the post-mortem room ; (2) 
that disease of the mesenteric glands is only exceptionally 
present unless it is accompanied by ulceration of the intes- 
tinal mucous membrane. I would further allude to the infre- 
quency of ascites in these cases. It seems possible that this 
may be due to the slow progress of the disease, during which 
it forms adhesions between various parts of the abdominal 

35 



4I4 THE DISEASES OF CHILDREN. 

cavity, and, therefore, in a great measure destroys the serous 
membrane. Ascites is the usual accompaniment of tuber- 
cular peritonitis — that form of disease in which the perito- 
neum is covered with sandy- looking grains; but this is an 
acute form of disease, and more commonly spreads to the 
still healthy serous surface from some cheesy mass in the 
omentum or between the liver and diaphragm. 

Localized patches of tubercle in the peritoneum are, in- 
deed, quite common in most cases of tubercular ulceration 
of the intestine ; but the difference is the same between these 
cases and those of generalized peritonitis as between chronic 
phthisis and acute tuberculosis of the lung. Here we have 
a chronic and acute tuberculosis of the serous membrane. 
I may further note the tendency which miliary tuberculosis 
of the peritoneum shows to be associated with miliary tubercle 
of other serous membranes, the pleura in particular. 

Diagnosis. — This is only to be made absolutely by being 
able to feel the glands. But wasting, nocturnal fever, 
abdominal pains, and brown, watery, offensive evacuations, 
combined perhaps with such slight local abdominal indica- 
tions as fulness, lumpiness, etc., will often make this as nearly 
certain as can be. 

As regards the glandular lumps, faecal accumulations are 
often puzzling; the question between them must be decided 
by having recourse to enemata and frequent examination. 
Both Hillier and Rilliet and Barthez allude to cases in which 
cancer of the abdominal viscera caused some difficulty — one 
in the pancreas, the others in the kidney. Such conditions 
must, however, but rarely trouble one, although large tumors 
of the kidney are not uncommon. It is, perhaps, of more 
importance to distinguish, if possible, between tabes mesen- 
terica and those cheesy masses to which I alluded at the 
commencement of the chapter; for although they are, as I 
said, often combined, yet cheesy masses of this kind some- 



TABES MESENTERICA AND TUBERCULAR PERITONITIS. 415 

times run a very chronic course, and may ultimately disap- 
pear. 

Prognosis. — In former times tubercular peritonitis and tabes 
were looked upon as hopeless. But, latterly, for both these 
diseases good evidence has been shown that they may recover. 
I have already alluded to Dr. Habershon's patient, who, 
years before her death from tubercular meningitis, suffered 
as it was supposed from tubercular peritonitis, and I have 
shown how this opinion was confirmed at the autopsy. I 
will say again, for it is an energizing fact, amid much that is 
grave and disappointing, that calcareous relics, by their 
presence upon the post-mortem table, not infrequently give 
evidence of the spontaneous cure of cheesy glands. Sur- 
geons in operating upon ovarian and other abdominal 
tumors, have sometimes seen tubercular disease of the serous 
membrane, and the patients have nevertheless recovered ; 
and, lastly, I may adduce as evidence — perhaps less satisfac- 
tory, but still worth regard after such unerring facts as these 
— that it is the impression of many physicians that these 
cases are by no means hopeless. 

The outlook will necessarily be grave; the result, in the 
majority of cases, fatal; but any thing which makes for re- 
turning health, such as absence of fever, diarrhoea, wasting, 
etc., may be seized upon as an indication for hope. 

Treatment. — However much one may hold to the con- 
stitutional origin of tabes, no one can hesitate to attrib- 
ute much of the immediate outbreak to catarrhal states 
of the mucous membrane of the bowel, and to the ab- 
normal work which falls upon the glands in consequence 
of inflammation and other conditions, the result of im- 
proper feeding ; and no one, also, can refuse to admit that, 
with the lacteals largely blocked and the glands practically 
destroyed, the preservation of life from starvation and the 
remedy for the disease must largely lie in the careful adap- 



4l6 THE DISEASES OF CHILDREN. 

tation of a diminished work to the diminished capacity of 
doing that work. In other words, the cardinal treatment of 
tabes mesenterica consists in the most strict attention to diet- 
ing the patient; giving no more food than is necessary, and 
seeing that the quality of that which is taken is such that 
the intestinal lacteals may have as little work to do as pos- 
sible. To this end it seems that beef juice, mutton broth 
freed from fat, chicken broth, eggs, and light fish afford the 
most appropriate diet. Milk and suet and fats should be 
given more sparingly, and carefully watched ; their assimi- 
lation can be accurately gauged by the state of the evacua- 
tions and the gain of weight under their administration. If 
they are digested, well and good ; if not, it is better to with- 
hold them for a while. Fat may in a measure be replaced 
by sugar under such circumstances, the absorption of which 
goes on readily, while vigorous inunctions may in some 
degree replace the fat which is temporarily withdrawn from 
the intestinal canal. Not only so, it may be as well in some 
cases, by the aid of the various digesting fluids which are 
now prepared, to get as much digestion accomplished out- 
side the body as is possible. The stomach will thus do 
more, the diseased surface less, and some rest will be given 
to the latter, so as to allow of the establishment of a more 
healthy state. 

As regards drugs, there can be no doubt of the good effect 
of tonics, such as iodide of iron and the various phosphatic 
preparations, whether phosphites or phosphates. As regards 
cod-liver oil, it is my belief that it is given too indiscrimi- 
nately, and often in too large quantity. Its digestion should 
be carefully watched, the child frequently weighed, and its 
evacuations examined, so that no more may be given than 
is well disposed of. Inunction, again, is a capital plan for 
administering the oil, but it is so repulsive a way that it 
cannot be strongly recommended, and in most cases I prefer 



TABES MESENTERICA AND TUBERCULAR PERITONITIS. 417 

olive oil for this purpose. Of other remedies, I believe chlo- 
ride of calcium to be of value, and, perhaps, small doses of 
iodoform. The former may be given to children three years 
old in five-grain doses with liquorice, and the latter from 
half a grain or so. If any lumps can be felt near the surface, 
a five per cent, solution of the oleate of mercury may be 
painted over the surface of the abdomen for four or five 
days, and repeated again at frequent intervals. In cases 
where there is much abdominal pain, small doses of Dover's 
powder are very useful ; two and a half grains may be given 
to a child of four or five twice or three times a day, if neces- 
sary. The child should be kept very warm, and removed 
to some dry air inland, or to some bracing seaside place. 

Tubercular peritonitis is best and sometimes very success- 
fully treated by the local application of mercurials. Some 
oleate of mercury may be painted over the abdomen, or a 
preparation of the ung. hydrarg. 5j, ext. bellad. 5j, glycerinae 
§j, ol. olivae ad §ij. Either of these painted over the abdo- 
men night and morning for three or four days will, perhaps, 
make the skin a little sore, if so, they may then be discon- 
tinued for a day or two, to be resumed in due course. 
Should there be much pain, warm linseed-meal poultices 
may be applied over the ointment ; and for cases in which 
there is much ascites, it is advisable to remove the fluid and 
envelop the abdomen with strapping, bandages, etc., so as 
to prevent, if possible, the accumulation of fluid, and to keep 
the parts quiet that adhesion may take place. The quiescence 
of the parts affected may be further encouraged by small 
doses of opium given internally. These cases are usually 
accompanied by fever, and the child is therefore necessarily 
kept in bed upon fluid diet. Should the acute symptoms 
subside, the abdomen should be well swathed in flannel, 
tonics should be administered, and the child taken as soon 
as possible into some good sea-side air. 



41 8 THE DISEASES OF CHILDREN. 



CHAPTER XXVIII. 

PERITONITIS AND ASCITES. 

Peritonitis sometimes occurs in the foetus, when it is due 
either to syphilis or to septic infection from the mother. 
Gerhardt states that many cases of congenital stenosis of the 
intestine are dependent upon peritonitis. 

In the newly born it is also septic, and occurs in associa- 
tion with unhealthy inflammation at the umbilicus. Again, 
it appears sometimes to be due to syphilis (West), associated 
with enlargement of the liver and spleen — which rapidly dis- 
appears under a mercurial treatment — and I have myself 
seen extreme ascites from this cause in an infant a few 
months old. 

In older children the remark holds good for peritonitis as 
for ascites, that most authors are inclined in many cases to 
attribute to chill an important share in its production. Some 
talk, also, of a rheumatic peritonitis ; and I have myself seen 
cases in which the question of a rheumatic origin crossed 
my mind, but which are valueless as evidence from the im- 
possibility of proving the point. 

Peritonitis may also occur after scarlatina or other fevers, 
when it is prone to be of a suppurative kind. But it is more 
often secondary than primary; that is to say, it is usually 
an extension from some disease of the viscera which the 
serous membrane envelops, or of parts in near proximity. 
Thus, it is not uncommon to find a local inflammation of the 
peritoneum which has extended from the neighboring pleura. 
It may occur also as the result of injury, and is sometimes 
due to rupture either of spleen or liver; in rare cases it may 



PERITONITIS AND ASCITES. 419 

be due to ulceration of the stomach, or gastritis. Sometimes 
again it is caused by the ulceration of typhoid fever; and — 
of more importance, because more frequent than any of these 
causes — ulceration of the caecal appendix may also be men- 
tioned. 

The symptoms are pain, fever, vomiting, and constipa- 
tion. 

[Their severity varies with the extent of the inflammation, 
the nature of exudation, and the acuteness of the course. 
The attack begins with rigor and vomiting of yellow or 
greenish mucus; then there is local or general abdominal 
pain, which is lancinating in character and increased by pal- 
pation and by the acts of coughing, vomiting, and deep 
breathing. This symptom continues almost to the close of 
the disease. The face is pale and anxious, the decubitus 
immovably dorsal with the knees drawn up, and the abdom- 
inal respiratory movements cease. The belly is distended, 
dull to percussion, and the presence of fluid is shown by 
fluctuation, that of fibrinous exudation, by friction sounds. 
There is loss of appetite and urgent thirst ; the tongue is dry 
and coated, and there is nausea, vomiting, hiccough, and con- 
stipation. The temperature is elevated, the pulse frequent 
and wiry, the respiration superficial, retarded, and superior- 
costal in type, and the urine often suppressed. In infants 
there may be convulsions ; in older children delirium. 

Should the disease become chronic the pain lessens and 
is more paroxysmal in character; the fever is remittent, 
with evening exacerbations. Constipation alternates with 
diarrhoea; there is great emaciation, and death occurs from 
exhaustion.] 

The diagnosis is often difficult ; ileus — which, however, 
is not a common affection in childhood — internal strangula- 
tion of any kind, and some of the more acute forms of en- 
teritis, will produce similar symptoms. 



420 THE DISEASES OF CHILDREN. 

The prognosis will depend upon the severity of the symp- 
toms. The more the vomiting, distension of abdomen, pain, 
rapidity, and wiriness of the pulse, so much the worse the 
case, as a rule. 

Treatment. — Opium must be given freely by the mouth, 
warm poultices applied to the stomach, and the patient fed 
upon the blandest diet, and very little of it. The child 
may suck ice, and take milk and water. Brand's essence, 
strong beef-tea, etc., by the spoonful. If necessary, nutri- 
ent enemata may be given, provided that they are re- 
tained. 

Typhlo-peritonitis. — I have purposely reserved ulceration 
of the csecal appendix for consideration as a disease of the 
peritoneum, because the student is apt to think much of the 
ulceration and less of the peritonitis. It is common to hear 
the disease talked of as perityphlitis, with some idea of 
disease outside the peritoneum in the sub-peritoneal tissue. 
But the whole importance of the affection lies in the fact 
that it is always a localized peritonitis, and not uncommonly 
a severe inflammation. A halting opinion on this point is 
fatal. An aperient given to drive on a scybalous concretion 
has over and over again led to the death of the patient by 
interfering with new-formed adhesions, and thus giving rise 
to a general peritonitis. 

Causes. — In my own experience the mischief has been 
more often due to impaction of a small scybalous concretion 
in the appendix caeci. But bodies of all kinds may pass into 
this part of the bowel and set up ulceration ; and the disease, 
moreover, not rarely occurs in tubercular subjects. It is an 
interesting question why the inflammation of the caecal ap- 
pendix should be more common in young than in older 
patients. That it is so, there can be no doubt. Several 
things may in part explain this. In the first place, it seems 
often to occur in such subjects as give indications of delicacy, 



PERITONITIS AND ASCITES. 421 

and sometimes it is associated with tubercle. The greater 
heterogeneity of diet in young people must also be taken 
into account, and also, too, the more active intestinal action, 
which is characteristic of the time of life.* Possibly, there- 
fore, small scybalous masses are more prone to v enter the 
vermiform appendix in young people, and, if the subject be 
scrofulous or tubercular, to start an insidious inflammation 
and ulceration. It not uncommonly comes on after pro- 
longed or excessive exertion. 

Symptoms are those of peritonitis, but it is a disease which 
varies much. It is often quite insidious in its onset, stomach- 
ache and irregularity of the bowels being the only com- 
plaints perhaps for several weeks. If it be more acute, 
there may be vomiting and constipation, with thickening in 
the region of the caecum, and in the worst cases it may be 
associated with such severe febrile disturbance as to be mis- 
taken for typhoid fever. 

The peritoneum is very treacherous in its reference of 
pain to particular spots. It is not uncommon for disease in 
one spot to cause pain in quite another, and for this reason, 
typhlo-peritonitis is likely to be overlooked. Therefore any 
griping abdominal pain of frequent recurrence should de- 
mand a careful examination by palpation of the abdomen, 
and one may hope to find some fulness, ill-defined thicken- 
ing, or definite induration to confirm the diagnosis if the 
disease be present. 

[The affections of the caecum and appendix occur so fre- 
quently and are of such importance that it seems judi- 
cious, before leaving this branch of our subject, to study 
them a little more in detail. 

a. Fecal distension of the caecum without inflammation 

* Abnormal position of the appendix is also an important element in the 
causation. This results from its length and the attachment of its mesentery. — 
Ed. 

36 



422 THE DISEASES OF CHILDREN. 

of its coats, gives rise to constipation, vomiting, and a 
doughy, slightly sensitive tumor in the right iliac region. 
If the accumulation be excessive, it may, by pressure, pro- 
duce numbness and oedema of the right leg, retraction of 
the right testicle, and even some change in the secretion of 
urine. 

b. Inflammation of the caecal mucous membrane may be 
acute or chronic. When acute there is moderate fever, pain, 
and tenderness in the right iliac region, and diarrhoea with 
mucous, ill-smelling evacuations. If chronic the patient be- 
comes pale and emaciated, the tongue is coated, the appetite 
impaired, the bowels are irregular, and the stools are apt to 
contain mucus and a small quantity of dark-colored blood. 
There is pain in the abdomen, and the caecal region is 
often full and tender to the touch. There is no fever. In 
these cases surrounding parts may become involved in 
the inflammation, or an attack of true typhlitis may super- 
vene. 

c Inflammation of all the coats of the caecum and ap- 
pendix or Typhlitis is attended by pain in the right iliac 
region, which is sudden in its onset and accompanied by 
marked tenderness to pressure. The patient lies on the 
back, somewhat inclined toward the right side, while the 
right thigh is flexed on the abdomen and any attempt to 
straighten it causes great suffering. The right iliac region 
is full, the abdominal wall in this position is tense, and when 
there is a large tumor there may also be numbness and 
oedema of the right leg and retraction of the testicle on the 
same side. There is usually obstinate constipation, occa- 
sional vomiting, fever, quickened pulse, anorexia, increased 
thirst, and a coated tongue. 

Should the inflammation be confined to the appendix 
there is less fulness of the caecal region, the pain is more 
intense, and no relief follows a free evacuation from the 



PERITONITIS AND ASCITES. 423 

bowels, a result to be expected when the caecum is chiefly- 
involved. 

When properly managed attacks of typhlitis should ter- 
minate in from three to five days; sometimes, however, they 
last for twelve days, or in severe cases several weeks may 
elapse before all the symptoms have passed away. Tender- 
ness to pressure is the most obstinate symptom, and until it 
has disappeared entirely the disease cannot be said to be 
cured. 

d. Perforative ulceration of the csecum and appendix 
gives rise either to a general peritonitis or to a localized 
peritoneal inflammation denominated perityphlitis, or, in the 
words of our author, " typhlo-peritonitis!' Should the perfo- 
ration occur in such a position that fecal matter mingled with 
inflammatory products enters the peri-caecal tissue, a fecal 
abscess is formed. The patient passes into a hectic condition, 
with rigors or even marked chills, followed by profuse 
sweating, a dry brown tongue, colliquative diarrhoea, rapid 
feeble pulse, prostration and emaciation. As the abscess 
approaches the surface the skin becomes dark-colored and 
doughy; on palpation there is distinct emphysematous 
crepitation, and on incision fetid gas and grumous matter 
escape. 

Perforation of the appendix usually produces general peri- 
tonitis. 

When the csecum is perforated without the production of 
general peritonitis (which is almost always fatal), a favorable 
result may be looked for in a large number of instances. Of 
the cases of fecal abscess, those reopening into the intestinal 
canal are most apt to get well, while of those pointing ex- 
ternally about one-half recover.* If the appendix be per- 
forated death almost uniformly results.] 

* Meigs & Pepper. 



424 THE DISEASES OF CHILDREN. 

Diagnosis, — In the absence of much local pain or swell- 
ing, and in the presence of general fulness of the abdomen 
and symptoms of blood-poisoning, it may be mistaken for 
typhoid fever. I have seen a child suffering from bright 
jaundice and fever where disease of the appendix caeci 
could only be surmised as being the most likely cause (by 
means of hepatic abscess) of the jaundice that existed. 
Local symptoms were quite in abeyance. Sometimes the 
local disease gives rise to an abscess which burrows in one 
direction or another, and which subsequently makes its ap- 
pearance in some other part of the abdomen altogether. 
On the other hand, it is sometimes difficult to distinguish 
between scybala in the bowel and inflammatory products 
around it; but, whenever there is any doubt, one should 
always err on the side of caution, as an aperient treatment 
may be most disastrous. 

Prognosis. — If the symptoms are at all acute, the disease 
is one of much danger. The more the vomiting and the 
constipation, the more the peritonitis, and, therefore, the 
more the risk. But it can hardly be taught too strongly 
that early recognition of the disease and appropriate treat- 
ment enhance considerably the chances of success. 

Treatment. — In all cases this is one of absolute rest. 
Opium and belladonna should be given internally; enemata 
used with caution to empty the rectum, and then to grad- 
ually empty the bowels from below, and poultices should 
be applied to the abdomen. In the more chronic cases I 
believe some advantage is gained by applying a five per 
cent, solution of oleate of mercury to the abdominal wall 
over the thickening; or the combination of mercurial oint- 
ment, extract of belladonna, and glycerine, already alluded 
to (p. 417). The diet will be similar to that for any other 
case of peritonitis ; iced milk and beef-tea in the early stages 



PERITONITIS AND ASCITES. 425 

of the inflammation, and later some relaxation of regime in 
the direction of custards, etc. 

Supposing that the disease becomes thoroughly localized, 
an abscess may form, and it is important to be aware of this 
and to be on the look-out for its occurrence. The parts 
must be very carefully handled, for fear of disturbing any 
adhesions; but attempts should be made, from time to time 
to ascertain whether there be any fluctuation or not. In 
such a case an early opening of the abscess will add mate- 
rially to the chances of the child's recovery. 

Care must be exercised for some time after any severe 
attack of this kind. The matting and adhesion of the parts 
is often considerable, and for long afterwards there may be 
pain on any active exertion ; there are not a few recorded 
cases where a want of caution has led to a recrudescence 
of the original malady — sometimes, unhappily, with a fatal 
result. 

Peritoneal Abscess, or localized suppurative peritonitis, 
occurs occasionally, and generally after scarlatina, or some 
other debilitating disease. The disease which has just been 
discussed might not unnaturally be supposed to occasionally 
produce it. 

In the three cases which have occurred to me, one was 
attributed to typhoid fever, one followed scarlatina at some 
considerable interval, and in one no cause could be assigned. 
In one of these cases the abscess had already opened spon- 
taneously at the umbilicus, from which there was a free dis- 
charge of thin pus. In the other two there was a diffused 
fluctuating swelling, dull on percussion, in the lower part of 
the abdomen. In one case there was severe constitutional 
disturbance ; in another, slight fever ; in the other, which 
had opened spontaneously, none. In all there was some 
abdominal pain. 

Diagnosis. — One of these cases was sent to the hospital 



426 THE DISEASES OF CHILDREN. 

for retention of urine, and the position of the swelling in the 
median line and lower part of the abdomen much resembled 
that of a distended bladder or miniature pregnancy. A 
positive opinion can hardly be arrived at without explora- 
tion. This was done by means of a hypodermic syringe in 
two of the cases alluded to. 

Treatment. — As soon as there is an evident collection of 
fluid which does not disappear by remedies — or should 
there be severity of the constitutional disturbances or other 
reasons requiring interference — an exploring syringe should 
be passed through the abdominal wall into the cyst, and, 
pus being found, a free incision should be made at that part 
which seems most suitable for the particular case. The 
contents of these abscesses are usually very fetid; never- 
theless, washing out the cavity need not be adopted imme- 
diately. It will be sufficient to allow free drainage by means 
of a drainage-tube; taking care, by the application of iodo- 
form, marine tow, or carbolic gauze, to keep the external 
parts as sweet as possible. Very foul cavities treated in this 
way have a good chance of becoming quite inoffensive within 
a few days. And, as with empyemas, I believe all inter- 
ference with the walls of the cavity is to be avoided if pos- 
sible. 

The wound must be dressed as often as necessary to 
remove the discharge, and, as this diminishes, the drainage- 
tube may be removed. 

The child must, of course, be kept in bed for some days, 
and fed upon the lightest diet, such as milk, beef-tea, blanc- 
mange, etc. A little Dover's powder may probably be neces- 
sary to relieve the pain for some few days. The bowels can 
be relieved by enemata, and subsequently some quinine, 
iron, and phosphoric acid will form a good tonic and help 
on recovery. 

Ascites is not a very common occurrence in childhood. 



PERITONITIS AND ASCITES. 427 

Apart from such obvious causes as diseases of the lungs, 
heart, kidneys, or liver, it may be due to tubercular peri- 
tonitis, or some tubercular affection of the abdominal glands. 
Yet it would appear that a simple dropsy of the peritoneum 
is of more frequent occurrence in children than in adults. 
Ascites is sometimes due to cirrhosis, and other enlarge- 
ments of the liver, such as syphilitic or lardaceous disease ; 
it may also be associated with enlargement of the spleen, or 
abdominal tumors, or with obstruction of the vena cava from 
enlargement of the retro-peritoneal glands. As regards 
what I have called simple dropsy, very little is known about 
it, save the fact that ascites sometimes comes and goes with- 
out any definite cause. Some think that exposure will lead 
to it ; others that it may be due to anaemia. 

[Should the quantity of fluid be small, the symptoms are 
very indefinite. If large, the abdominal wall is arched for- 
ward, and fluctuation is distinct. When the patient lies 
upon his back, percussion is tympanitic over the upper 
and anterior parts of the belly, where the intestines float 
free, but dull elsewhere ; a change in position alters the 
relation of the areas of dulness and tympany. The superfi- 
cial veins are prominent, and the umbilicus may protrude. 
Respiration is embarrassed, the bowels are constipated or 
relaxed ; there is painful micturition, and the urine is often 
diminished in quantity, and contains albumen, blood, and 
tube-casts.] 

Diagnosis. — Ovarian tumors rarely occur in childhood ; 
nevertheless, such sometimes happen, and a tumor of this 
nature may easily be mistaken. Hydronephrosis might also 
lead to mistake, and also large hydatid tumors in the liver 
or elsewhere. 

Treatment. — This must depend upon the cause; but, per- 
haps, the most important points to bear in mind are the 
necessity of reducing the quantity of fluids given to the 



428 THE DISEASES OF CHILDREN. 

child, and of giving iron in cases in which no cause can be 
discovered. The iron may be given as the iodide or the 
saccharated carbonate of iron, and diuretics (other than 
copious imbibition) can be given as well. The resin of 
copaiba seems to be exceptionally useful in adults in cases 
where there is a healthy kidney ; but I have not tried it 
much in children, although there is no reason save the taste 
against its use. Digitalis and squill can be made more 
palatable ; and, again, a local application of oleate of mer- 
cury or mercurial ointment to the abdomen is of value.* 

If the fluid does not diminish after a good trial, paracen- 
tesis should be performed. This operation is not only pal- 
liative, but it is a remedial agent of great value. I prefer 
the use of a very fine canula, such as that called a Southey's 
tube. A drainage-tube is attached to this, the canula is left 
in, and Jhe fluid allowed to drain away for some eight or ten 
hours. The abdomen should be carefully bandaged the 
while, and continuous pressure must be kept up afterwards. 
The fluid is not all removed by this means, but enough is 
withdrawn to relieve pressure and allow of absorption. 
Moreover, the operation of paracentesis on this plan is so 
slight that the child is hardly frightened by it, and it can be 
repeated in like manner when necessary. 

* A course of hydragogue cathartics often gives most satisfactory results. — 
Ed. 



DISEASES OF THE SPLEEN. 429 



CHAPTER XXIX. 

DISEASES OF THE SPLEEN. 

Diseases of the spleen are only to be recognized clini- 
cally by pallor — which sometimes possesses a peculiar tint 
— and by an enlargement of the organ. A diseased spleen 
is usually an enlarged spleen, and therefore few cases should 
escape notice. 

Causes. — Splenic enlargement is a very common affection 
in children, and is generally due to one or other of the follow- 
ing conditions — rickets, syphilis, ague, tubercle, typhoid 
fever, or to some cause unknown. Having said this, the 
student is in possession of the more common causes of 
splenic disease. The enlargement of leucocythaemia occurs 
occasionally. Some increase of size and alteration of struc- 
ture is sometimes found with Hodgkin's disease; lardaceous 
disease is common in children, and cirrhosis of the liver 
may occasionally be associated with some splenic swelling ; 
but in all these the one change, being coupled with others 
which have general symptoms of more prominent kind, is 
of less importance, and the description of the same form of 
disease in the adult will apply to that in the child. The 
symptoms of lardaceous disease, of Hodgkin's disease, of 
cirrhosis of the liver, are all sufficiently distinctive. In the 
affections enumerated above the spleen may be the only 
part to attract attention," over and above the pallor that 
exists. As regards the frequency of the various forms of 
enlargement, of seventy-four cases of which I have notes, 
twenty were associated with well-marked rickets ; in twenty- 
four others the rickets was very little indeed, or none at all, 



430 THE DISEASES OF CHILDREN. 

and the disease could not in these cases be with certainty- 
attributed to this or indeed any other cause — some may 
have been due to pulmonary obstruction, some, perhaps to 
ague ; fourteen were in syphilitic children ; in ten it was a 
part of a general tuberculosis. Of the remainder, two were 
febrile cases, three leukaemic, and one the result of ague. The 
enlargement which is due to typhoid fever has so brief a 
mention because it finds its appropriate place under the dis- 
ease to which it belongs. 

Morbid Anatomy. — Rachitic and simple chronic enlarge- 
ments usually show similar appearances. The spleen is 
large, its capsule perhaps a little thick, its substance firm, 
pale or dark-colored, and under the microscope the fibrous 
septa of the organ are thickened. Dr. Dickinson has made 
a valuable contribution to the histology of the rachitic 
spleen, and considers the disease to be a fibrosis. I have 
seen hyaline thickenings of the septa that might be called 
fibrotic in four cases which I have examined. As is well 
known, an albuminoid change has been described by Sir 
W. Jenner as peculiar to rickets, but this can only occur 
in the more extreme cases, and it is decidedly uncommon. 
I have never seen it, and Dr. Gee only occasionally. 

There is hardly enough evidence at hand to prove what 
are the precise changes which a syphilitic spleen undergoes, 
but its coarse appearances are usually such as are seen in 
simple chronic enlargement. The tubercular spleen has, 
scattered over the surface of its capsule, many large juicy- 
looking gray miliary tubercules ; and similar bodies are 
spread thickly through its substance. Either on the cap- 
sule or in its substance, but particularly the latter, the 
tubercles are often caseous and appear as small yellow 
grains. 

Symptoms. — Enlargement of the spleen goes almost con- 
stantly with pallor, which is sometimes peculiar in the depth 



DISEASES OF THE SPLEEN. 43 1 

of its sallowness and sometimes in the tint being slightly 
brownish or green. 

Diagnosis, — There are no special points about the dif- 
ferent diseases which enable one to distinguish one form of 
enlargement from others. The various causes I have enu- 
merated must be kept in mind, and other symptoms of the 
special disease examined for. I have, however, thought in 
the two diseases which are so difficult to distinguish from 
one another, typhoid fever and acute tuberculosis, that the 
spleen of the one could sometimes be distinguished as soft, 
and that of the other as hard. It may also be said that the 
tubercular and the syphilitic spleen are both more often 
associated with enlargement of the liver than are rachitic 
and simple chronic enlargement of the spleen. 

The blood is usually very abnormal in these cases. I 
have made a large number of examinations, and the condi- 
tions are fairly constant. The blood is wanting in haemo- 
globin — sometimes as much as sixty per cent, being absent, 
if measured by the haemoglobinometer. The red corpuscles 
are diminished — it may be as much as three-fifths of the 
whole — and a moderate excess of colorless corpuscles oc- 
cupies each field of the microscope, some of them large, 
others much smaller than common. Various stages of 
development of the red corpuscles can also usually be 
seen, to judge from the variety of size that may be met 
with, from free granules up to the normal-sized red cor- 
puscles. 

Prognosis, — All splenic enlargements are liable to prove 
intractable. Even those of syphilitic origin, which might 
be expected to answer readily to drugs, respond but tardily 
in comparison with other viscera. It is a common thing to 
find the liver decreasing rapidly in size, while the spleen has 
altered but little. As a rule, they slowly improve in the 
course of months. I have known one or two cases to 



432 THE DISEASES OF CHILDREN. 

waste steadily and to die — no cause, rachitic or other, being 
found post mortem to explain death, except the enlargement 
of the spleen. 

Treatment, — The spleen of ague or of syphilis will re- 
quire the remedies appropriate to those diseases. All 
forms, associated as they are with pallor, will require careful 
blood restoring, either by arsenic, iron, cod-liver oil or sea 
air. 

The rachitic and the chronically enlarged spleen do best 
upon beef juice or raw meat, and the syrup of the lacto- 
phosphate of iron in half-drachm doses ; a varied diet of 
good food and plenty of fresh air being supplied meantime. 

One may venture to suspect, from the slow progress of all 
cases of enlargement of the spleen, that, given a certain 
duration of the morbid condition, changes take place in the 
circulation through the organ which make a rapid return to 
normal impossible, and it therefore seems advisable to resort 
to external aid, such as gentle friction over the surface of 
the organ by oil or soap liniment in addition to other means, 
for, although no striking success can be hoped for, some 
may possibly be achieved. 



DISEASES OF THE LIVER. 433 



CHAPTER XXX. 

DISEASES OF THE LIVER. 

There is not much to be said on this head. The liver is 
not an organ which is frequently diseased in childhood, 
though perhaps there is no one of the hepatic diseases of 
adult life which may not, as an occasional thing, find a home 
or have its birth in children. 

The most common affection would seem to be simple jaun- 
dice, which may be found at any age — at birth, when it is 
called icterus neonatorum, and in older children, when it 
may be due to a variety of causes, but is, perhaps, chiefly 
" catarrhal." 

Icterus Neonatorum is of two forms, physiological and 
morbid. In the one case it is merely a yellowness of the 
skin, due to changes which ensue in a congested skin at the 
time of, or soon after, birth. It is said to be more frequent 
in premature infants. In this case, the conjunctiva and 
urine remain free from color, and the faeces retain a natural 
appearance. It passes off within a few days, and is not of 
any moment. It requires no treatment. 

Icterus due to disease is a more serious matter, but the 
outlook will depend greatly upon the nature of the cause of 
the jaundice. In some cases it appears to be due to a simple 
catarrh of the ducts, or to some defective circulation in the 
liver in the first few days of life, or to exposure to cold, it 
being particularly frequent in foundlings. These conditions 
may all be expected to pass off by warmth, and some gentle 
laxative, such as hyd. c. cret. or castor oil, within a few days. 
But in other cases it is due to some congenital malformation, 



434 THE DISEASES OF CHILDREN. 

some syphilitic thickening of the ducts, or to some inflam- 
matory or phlebitic affection of pysemic origin, which has 
started in the umbilical sore. Such things lead almost 
inevitably to death, and in no long time; but cases are on 
record in which children have lived for some weeks, or even 
months, with such serious malformations as an absent com- 
mon duct.* Death usually results from hemorrhage from 
the umbilicus or from a more gradual wasting and exhaus- 
tion. Diseases of this kind hardly admit of treatment. 

Jaundice in older children is usually a temporary thing, 
and is thought to be due to catarrh of the ducts. The jaun- 
dice is not usually very deep, and a few days sees the end of 
it. Some mild laxative, such as the compound decoction of 
aloes, a little liquorice powder, syrup of rhubarb, or fluid 
magnesia, is the only remedy that is requisite if the diet be 
restricted. But in a case of jaundice, where the child has 
fever or vomiting, it is well to remember that icterus some- 
times follows suppuration in the branches of the portal vein 
(pylephlebitis) or masked disease about the caecum, or else- 
where, and that such other things, as acute yellow atrophy, 
enlargement of the mesenteric and lumbar glands, etc., may 
exist, and give rise to the symptoms. I have also several 
times seen acute tuberculosis give rise to considerable en- 
largement of the liver and moderate jaundice. 

Of hydatid disease, lardaceous disease, and fatty degenera- 
tion, I shall say nothing, for they present no special pecu- 
liarities in childhood ; nor of cancer (sarcoma) of the liver 
need more be said than that when it occurs, which is very 
rarely, the growth is usually soft, lobulated, and very rapid 
in its spread. It is far less common than sarcoma of the 
kidney. I have seen five of the latter to one of the former. 

* Dr. F. B. Nunneley records the case of a child who lived nearly seven 
months with congenital obliteration of the hepatic ducts : " Trans. Path. Soc. 
London," vol. xxiii., p. 152. 



DISEASES OF THE LIVER. 435 

The albuminoid disease of rickets will receive sufficient 
notice in the article on rickets. 

Tubercular Disease requires mention, because it may 
cause considerable enlargement of the liver, which, except 
for this knowledge, may prove inexplicable, or more prob- 
ably be attributed to quite a wrong cause. I have lately 
seen such a case, which was supposed to be cancer, but my 
diagnosis of tubercle was proved to be correct by the post- 
mortem examination. There is usually some jaundice in 
these cases. The disease in the lung may be quite latent 
till towards the close. The liver may show either of two 
appearances, or the two more or less combined. There may 
be yellow caseous softening masses spread through the 
liver, which may be seen to be tubercular growths around 
the smaller bile ducts ; or else there is an extensive miliary 
tuberculosis of the organ, in which the texture is irregularly 
stuffed with the lymphoid tissue; some parts being con- 
gested, and some fatty; and the tout ensemble showing a 
large mottled, sometimes nutmeg-like appearance. 

Cirrhosis of the Liver is found in all respects like that of 
adults. Its chief interest, perhaps, centres round the discus- 
sion of its cause; some having contended that in children it 
is not due to alcohol, and that some additional light is thus 
thrown upon the pathology of the disease in adults. There 
is no space here to be more than dogmatic, and I must con- 
tent myself by saying that even in children some of the 
recorded cases have been due to alcoholism ; and that in 
others there has been no sufficient disproof of the possibility 
of such an exciting cause. As Gerhardt says, alcoholism 
in childhood is very difficult to prove. It is probable, how- 
ever, that it is not by any means the sole cause of infantile 
cirrhosis, though what the other causes may be we at pres- 
ent know but little. It is not unlikely, however, that some 
cases may be explained by congenital syphilis, and others, 



436 THE DISEASES OF CHILDREN. 

by changes, either congenital or commencing in early in- 
fancy, of a very chronic hyperplastic character around the 
ducts or veins. Intermittent fever and phthisis have also 
been found associated with it. Cirrhosis of the liver is not 
a disease of early infancy ; a very few cases are on record in 
the new-born, but it is most common at the age of about 
seven or eight years. And it must be admitted that in the 
majority of cases the early history and onset have been ex- 
ceedingly obscure. 

The symptoms are for the most part a precise reproduc- 
tion of those which occur in adults ; perhaps it may be said 
that splenic enlargement is more constant than in the adult, 
and that diarrhoea is a more prominent symptom. Ascites 
has been extensive without much jaundice in all the cases I 
have seen. 

Morbid Anatomy. — In most of the cases the liver has 
been markedly granular and fibrous throughout ; in some 
there has been extensive scarring, and consequent distor- 
tion, so as tD give some color to the idea that syphilis has 
been at work. The histological changes have been mostly 
those attending the more chronic forms of the disease — that 
is to say, more fibrous than cellular. The earlier stages of 
enlargement of the viscus and new growth of cell elements 
have been described as in adults, and no doubt occur, but 
are likely to escape notice until the onset of ascites. 

The prognosis and treatment require no special mention. 

Syphilitic Hepatitis may be of three kinds. The liver 
may be subject to acute swelling, which, without showing 
very much change to the naked eye, is associated with a 
diffused cell-growth throughout the organ, either scattered 
or gathered into miliary gummata ; there may be a localized 
gummatous change here and there, as in adults ; or, as in a 
case recorded by Dr. Barlow, scars of retrocedent gummata ; 



DISEASES OF THE LIVER. 437 

or there may be a nodular or streaky affection of the septa 
— a peri-pylephlebitis syphilitica. 

In any case there may be adhesions about the capsule of 
the organ. 

All these changes are chiefly met with in the full-time or 
premature foetus, or in the first few weeks of life. Cicatrices 
or a diffused swelling appear to be the commoner forms of 
the disease. Dr. Wilks has recorded a case of the latter 
kind in an infant of four weeks old,* and Gubler, V. 
Baerensprung, and Wagner have gone carefully into the 
subject, but there are not many complete cases on record. 
The liver is enlarged, hard, and elastic, creaking under the 
scalpel, and torn with difficulty ; it is often pale or mottled. 

In the few cases that I have seen, the microscopical char- 
acters of the disease have been remarkable for the extreme 
degree of cell-growth that has occurred, so much so that it 
has been difficult, if not impossible, to give an opinion upon 
the mode of invasion which the disease has pursued. The 
hepatic cells were inextricably mingled with those of the 
syphilitic growth, nearly all trace of the natural structure 
having been lost. This condition is not unimportant in re- 
gard to the subsequent occurrence of cirrhosis. It would 
seem to be one that, if not fatal in itself,, is pre-eminently 
likely to produce a subsequent cirrhosis ; and no doubt it is 
one of the facts upon which those may rest who consider 
that the cirrhosis of older children is in some cases due to 
syphilis. The spleen is often enlarged as well as the liver. 

Symptoms. — The liver may be much enlarged and hard. 
There may be ascites and some amount of jaundice. The 
following case will illustrate these points : 

A male infant, aged two months, was brought to the hos- 
pital for enlargement of the abdomen, which was much dis- 

* "Trans. Path. Soc. London," vol. xvii., p. 167. 
37 - 



43^ THE DISEASES OF CHILDREN. 

tended and shiny, and the veins in the wall large and full. 
The abdomen had been gradually enlarging since a fort- 
night after birth. The liver was much enlarged and bossy, 
extending halfway to the umbilicus, its edges being sharp 
and well-defined. The spleen was very large also. 

The child was much wasted and pale, its mouth wrinkled, 
but there was no other trace of syphilitic eruption in any 
part of the body. 

It was treated by a grain of hyd. c. cret. night and morn- 
ing, and rapidly improved, gaining flesh rapidly, and the 
liver and spleen, the former particularly, diminishing much 
in size. This child was under treatment, on and off, for 
four years for various ailments, an attack of snuffles 
amongst them, and remained quite well as regards its liver 
and spleen. During this time another infant was born, and 
this also was under treatment for well-marked congenital 
syphilis. 

Diagnosis. — There can hardly be any mistake. Setting 
aside the fact that enlargement of the liver and spleen at 
this early age are rare, except in syphilis, there are the re- 
cognized symptoms in the parent and in the child itself, 
which should in most cases clear up any doubt. 

Prognosis. — Steiner remarks that these cases are usually 
fatal ; but such has not been my experience. Judging from 
some eight or ten cases they seem to be remarkably amenable 
to mercurial treatment, as was the case first detailed. Under 
mercurials the liver will rapidly diminish ; the spleen is, as 
I have already said, less easily acted upon. 

Treatment. — A grain of hyd. c, cret. may be given every 
night, or night and morning, for two or three weeks, or 
longer if necessary, and some syrup of the iodide of iron 
may be added later. 

Functional Disease.— Far more frequent than cases of 
organic disease are instances of what is popularly termed 






DISEASES OF THE LIVER. 439 

sluggish liver — children whose bowels are habitually con- 
fined and the evacuations pale and deficient in bile. Thus, 
in effect, says Dr. West,* who has described these cases so 
concisely that it seems unadvisable to do otherwise than 
copy him : " Without being positively ill," he says, " chil- 
dren thus affected are usually sallow and look out of health ; 
their appetite is variable, and their tongue never quite 
clean." And, as related to these, Dr. West alludes to the 
cases of older children who, with good health and regular 
habits, yet every few weeks or months have a bilious attack 
with severe headache. Of the nature of these last cases 
there may well be a doubt. Many would be inclined to 
consider them less as hepatic diseases than as illustrations 
of megrim or some allied disorder, but the former class are 
less equivocal. The habits are irregular, the excreta pale, 
the tongue furred, and the breath foul, and attention to the 
bowels and the functions of the liver mends matters consid- 
erably. 

Treatment. — In this condition euonymin is a good 
remedy — a quarter to half grain with some white sugar 
twice or three times a day. If the bowels do not act, the 
euonymin may be given with some cascara sagrada, or the 
compound decoction of aloes, or sulphate of magnesium, 
with the compound infusion of roses. Nux vomica, 
hydrochloric and phosphoric acid are also useful in these 
cases. 

Lithaemia. — Other cases, which may also be called hepatic, 
give evidence of disturbances which are chiefly urinary. A 
child perhaps of three or four years old becomes fretful. It 
may seem pretty well, but perhaps suddenly, and frequently, 
will cry, quickly recovering itself and resuming its play. 
With this disturbed mental equilibrium there is frequent 

* " Diseases of Children," 5th edit., p. 607. 



440 THE DISEASES OF CHILDREN. 

micturition, and the urine deposits a thick pink sediment of 
urates. This is the condition which in older people, and 
with more variety of symptoms, Murchison denominated 
lithaemia. It is often associated with irregularity of bowels. 

Treatment. — The meat in the child's diet should be tem- 
porarily reduced or stopped. Fish may replace it. or the 
child be confined to milk and egg diet for a few days, and 
at the same time some effervescing citrate of magnesium 
may be given twice or three times a day. 

These are also cases which are benefited by euonymin or 
the decoctum aloes co., one or two teaspoonfuls three times 
a day. 



DISEASES OF THE GENITOURINARY ORGANS. 



441 



CHAPTER XXXI. 



DISEASES OF THE GENITO-TJRINARY ORGANS. 



The larger number of diseases of this class the physician 
is not called upon to treat. The greater number of malfor- 
mations of bladder and external organs, stone in the bladder, 
balanitis, phimosis, hydrocele, etc., fall entirely into the 
hands of the surgeon. Of these I shall only say so much 
as concerns us ; but others have a more entirely medical 
aspect. To begin with, it may be well to remark briefly 
upon some of the not infrequent morbid conditions of the 
urine in childhood. They are but symptoms, it is true ; but 
their consideration as definite conditions saves both time and 
repetition. 

Hematuria occurs under a variety of conditions, as the 
result of purpura, of scrofulous disease of the kidney or 
bladder, of calculus either renal or vesical; it is not uncom- 
mon as the result of small growths about the urethra of 
the female child, and may, of course, be present as the re- 
sult of nephritis, of renal tumor, or of cystitis. But besides 
all these, and more puzzling than they, children are brought 
to the out-patient room with a history of frequent passage 
of blood in the urine. Perhaps they are admitted, and the 
blood present once or twice within the first few hours dis- 
appears altogether, and does not reappear. It is difficult to 
say whence the blood comes in these cases. In some it 
may be derived from the kidney, in association with the 
presence of uric or oxalic acid in excess in the urine ; in 
some, perhaps, it is vesical, in association with the local 
congestion and irritation of ascarides ; possibly some may 



442 THE DISEASES OF CHILDREN. 

be cases of hemoglobinuria, of which I have lately had an 
example in the case of a little girl in hospital. All these 
things would disappear under the warmth, careful feeding, 
and mildly laxative regimen of a hospital. At any rate, I 
can say nothing more positive for the guidance of the stu- 
dent. The blood is sometimes passed in large quantity in 
these cases, the urine being port-wine-colored and full of 
blood ; and the feature of the case is, that it comes and 
goes quite suddenly, and there is no symptom of ill-health 
of any kind. There may be a little frequency of micturi- 
tion, and on several occasions the child has been sounded 
for calculus on this account, but without the detection of 
any cause for the hemorrhage. The following case may 
serve to impress some of these points upon the reader : 

A girl, set. seven, was admitted into the Evelina Hospital 
with the history that she had been passing blood in her 
urine occasionally for four months. She was sent to the 
hospital by Mr. Duke. She had had scarlatina twelve months 
before. Four months ago her mother first noticed that the 
urine was like dirty tea, thick, and — after standing — deposit- 
ing a large quantity of red sediment. The child had never 
complained of any pain, and there had been no swelling of 
any part of the body, save that once or twice the mother 
thought that her child's eyes were rather puffy. For six 
weeks past there had been blood in the urine. The color 
of the blood was natural, well mixed with the urine, but there 
were some clots also. When she was admitted, I remarked 
that some of the features were those of vesical growth, but 
that it was a frequent hospital experience that children, with 
prolonged hematuria outside, speedily got well inside the 
hospital. So it proved to be. The urine on admission con- 
tained a quantity of blood, well mixed with the urine when 
passed, and a microscopic specimen consisted in great mea- 
sure of blood corpuscles, sp. gr. 1024, albumen one-eighth, 



DISEASES OF THE GENITOURINARY ORGANS. 443 

no- casts of any description. The child was admitted on the 
8th of the month, and up to the 10th there was still much 
blood. On the 12th it was only indicated by the guaiacum 
test; on the 14th, more blood again; 15th, none; 16th, 
none; 18th, much, with a sediment of dark-brown grumous 
matter, a few granular casts, and much albumen, sp.gr. 102 1, 
the character of the urine being quite that of renal disease. 
From this date only a trace of blood appeared once, but 
albumen appeared twice. She left the hospital three weeks 
later, apparently quite well. This child was never ill, never 
in pain, save that once she had an attack of abdominal pain 
while in the hospital, which might, perhaps, have pointed 
towards a renal calculus. 

The indication is in all such cases to examine for all the 
diseases which are known to produce haematuria, particu- 
larly for nephritis, for calculus in the bladder, for ascarides 
with prolapsus ani in either sex, and for some vesical growth 
in the female. Failing to find any disease to which to at- 
tribute the symptoms, the child must be kept in bed and 
watched, some gentle aperient being given, and probably 
some alkaline diuretic, the diet being kept for a day or two 
to milk food or fish. If the bleeding be severe, it may be 
advisable to give a little gallic acid, some tincture of hama- 
melis, or possibly a little turpentine. 

Anuria, or temporary suppression of urine, is a frequent 
affection in infants, and sometimes seems to depend upon an 
excess of uric acid in the urine. It is a condition which 
lasts but a few hours at most, is generally evidenced by 
symptoms of pain or discomfort when micturition takes 
place, and the urine, when examined, is found to be concen- 
trated, highly acid, and to have deposited a copious sedi- 
ment of urates or angular crystals of uric acid. 

[The application of flannel cloths wrung out of hot water 
over the lower part of the abdomen, together with small 



444 THE DISEASES OF CHILDREN. 

doses of sweet spirits of nitre, usually relieves this condition 
quickly.] 

Dysuria. — The infrequency of micturition of infants just 
mentioned is replaced by frequency and pain in older chil- 
dren. The characteristics of the urine are the same. 

Causes. — Errors in diet and gastro-intestinal derange- 
ments appear to be the chief causes of these complaints, and 
they are frequent during dentition ; but it is not improbable 
that, as Dr. West remarks, they are frequently part of a con- 
stitutional tendency, and are liable to occur in children of 
rheumatic or gouty extraction. They are usually temporary 
ailments, but sometimes, in children of six or eight years of 
age, the passage of lithates or lithic acid may be associated 
with evidences of more prolonged ill-health. I have already 
alluded to this class of cases under hepatic diseases, to which 
of right they more properly belong. 

Diagnosis. — Care must be taken to exclude scrofulous 
pyelitis, calculus, urethral growths, or rectal troubles. 

Treatment. — Any errors in diet are to be corrected. 
Probably the quantity of food should be lessened, and fish 
rather than meat be given for a few days. As a medicine, 
it is generally sufficient to give some one of the laxatives 
already recommended — citrate of magnesium, compound de- 
coction of aloes, etc., or sulphate of magnesium (F. 12). In 
such cases as seem to suffer from any prolonged ill-health, 
some dilute nitric or phosphoric acid, with the tincture of 
yellow bark, may be given with advantage. 

Polyuria, like haematuria, is in many cases difficult to sub- 
stantiate. It is the complaint of many a mother as regards 
her child, but under hospital regimen it is the rarest thing 
possible. It may be occasionally due to saccharine diabetes. 

Not long ago, a girl, aet. seven, was admitted to the hos- 
pital, who was said to have passed as much as half a gallon 
of urine in one night, and who had had polyuria, thirst, and 



DISEASES OF THE GENITOURINARY ORGANS. 



445 



wasting for three months. She continued to emaciate, and 
died without any adequate cause being discovered at the 
autopsy; but, while in the hospital, her urine was never ab- 
normal in any way. 

Pyuria. — Pus in the urine may come from cystitis from 
any cause, from scrofulous disease of the kidney, its pelvis, 
or ureter, from stone in the kidney (and, of course, in the 
bladder), and from any vaginal or pudendal discharge. 

Spontaneous cystitis would appear to be not so very un- 
common, and for the most part is associated with some 
febrile disturbance, together with frequency and pain in mic- 
turition, whilst the urine contains pus. Dr. Gee* records a 
case in a child of nine months, in which micturition was 
painless and not more frequent than usual. In some of 
these cases I suspect that the cystitis originates in some 
vaginal discharge, and spreads backwards. 

A girl, set. four years, had suffered from vaginal discharge 
for four or five months. For a week before she was admit- 
ted, she had had frequent and straining micturition, and 
screamed when passing water. The urine was faintly alka- 
line, contained a small quantity of albumen, and a large 
deposit of flocculent pus. She was examined under chloro- 
form, and plenty of pus issued from the urethra, but no cause 
for the cystitis could be discovered. She was treated with 
salicylic acicl (five-grain doses every four hours), and the 
micturition quickly became less frequent, and the pus grad- 
ually disappeared from her urine. The duration of the ill- 
ness was six weeks. 

Treatment. — For such cases as these the child must be 
restricted to milk foods, and salicylic acid may be adminis- 
tered internally. Dr. Gee recommends benzoate of ammo- 
nium and pareira brava. 



* On some kinds of Albuminous and Purulent Urine in Children : 
Med. Journ.," vol. ii., 1883, P- 961. 

38 



Brit. 



44^ THE DISEASES OF CHILDREN. 

Pyuria of longer duration is more likely to be due to some 
scrofulous condition of the kidney (when perhaps it may be 
possible to distinguish some enlargement of the organ by 
palpation of the loin), or to stone. 

Scrofulous Kidney may be associated with pain in the 
loin, with frequency of micturition, and with a flocculent 
purulent sediment of pus in the urine, occasionally with a 
streak or two of blood; but it is quite necessary to remem- 
ber that it may be present also without any characteristic 
symptoms. The usual course of these cases is, after com- 
mencing in the renal pyramids, to produce gradual erosion 
and excavation of the organ, and extension of the disease 
along the ureter to the bladder; but in the male there are 
often separate centres of caseous disease in epididymis and 
prostate, and these parts should be examined in the hope of 
throwing some light upon the diagnosis. The disease is uni- 
lateral in the sense that one kidney is generally much more 
involved than the other, but it is seldom confined entirely 
to one organ in old standing cases. The kidney in the late 
stage is much enlarged. Patients with scrofulous kidney are 
subject to the risk of the outbreak of a general tuberculosis. 

Treatment. — In the early stage, every effort should be 
made to improve the child's health. There is plenty of clini- 
cal evidence to show that scrofulous disease of the urinary 
passages is often of very slow progress ; there is plenty of 
evidence from the post-mortem room, in the existence of 
calcification and tough fibrous tissue, that the disease un- 
dergoes processes of repair, and often becomes encapsuled. 
Therefore, in the early stage, resort should be had to sea-air, 
pure air, good living — in the way of cream, cod-liver oil, and 
food. 

As drugs, chloride of calcium should be given internally, 
or, perhaps, iodoform, if it can be taken. In the advanced 
stage, where there is a permanent and profuse discharge of 



DISEASES OF THE GENITOURINARY ORGANS. 



447 



pus which nothing can control, much pain and distress 
from frequent micturition, and progressive anaemia, an ex- 
ploratory operation should be performed, and the kidney 
drained, and possibly, should it be necessary, subsequently 
removed. 

Renal calculus is sometimes, though by no means neces- 
sarily, associated with definite colic and hematuria. A 
simple chronic or intermitting pyuria, with some irritability 
of the bladder, may be all that points to the existence 
of stone. Calculus in the kidney is not uncommon. It 
will not be always possible to make a diagnosis; but by 
keeping the possibility of its presence in mind perhaps, 
after these few suggestions, a mistake may sometimes be 
avoided. 

[Concretions in the kidneys occur in two forms : uric acid 
infarctions, and calculi varying in size from that of a pin's 
head to that of a cherry-stone. 

Uric acid infarctions are found in the kidneys of infants 
who die a few weeks after birth, and in those in whom the 
respiratory function has been imperfectly performed during 
life. On section the organs present a regular and well- 
marked orange streaking of the pyramids, due, as the 
microscope shows, to the deposition of reddish-yellow crys- 
tals of uric acid between the epithelial layers of the straight 
tubes. 

When an originally insufficient respiration becomes 
normal, the urinary excretion is increased, the infarctions 
are washed out and may be found upon the diaper in the 
form of minute red particles. 

Calculi have for their starting-point portions of infarctions 
left behind in the kidney, or arise during the course of dis- 
eases in which the quantity of urine is diminished. Their 
presence in children of three or more years may be indicated 
by the appearance of minute granules in the urine, by strain- 



44$ THE DISEASES OF CHILDREN. 

ing or pain in micturition, and sometimes even urethral 
spasm. Should the concretions be passed into and retained 
in the bladder, they increase gradually in size. When 
retained in the pelvis of the kidney they may give rise to 
suppurative pyelitis. 

Alkaline waters, a non-albuminous diet, and warm baths 
for stricture or pain, constitute the remedial measures.] 

Acute Nephritis has already been sufficiently dealt with 
as regards symptoms and treatment under the head of scar- 
latinal dropsy (p. 179). But it will be well here again to 
introduce the subject if only to express the conviction which 
many now entertain, that there has been far too much dog- 
matism concerning the scarlatinal origin of all cases of 
nephritis. It has been the custom to inquire for a history 
of scarlatina in all cases of albuminuria, and, whether eliciting 
it or not, to assume that it must have preceded the disease. 
But apart from all evidence of pre-existing scarlatina, the 
burden of proof, as Dr. Gee remarks, lies upon him who 
affirms that such nephritis must needs be scarlatinal. I 
have seen so many cases in which it was impossible to ob- 
tain the least evidence of scarlatina, that I have long taught 
that a spontaneous nephritis is not uncommon in children 
of all ages ; and I am glad to see that Dr. Gee has lately 
stated that this also is his belief, as it is also of Dr. Ashby. 
Dr. Gee, in his paper on this subject,* alludes to the fact that 
acute nephritis may be wholly latent, and that the nature of 
the disease will certainly escape notice if the urine be not 
always examined as a matter of routine. There may be 
fever, vomiting, and even coma, and per contra, there need 
not be any fever or any dropsy. 

For the treatment of such cases the reader may refer 
to the paragraph relating to the treatment of scarlatinal 
dropsy. 

* Loc. cit. 



DISEASES OF THE GENITOURINARY ORGANS. 449 

[Chronic Bright's disease in children presents the same 
pathological appearances and symptoms, and requires the 
same methods of treatment as in adults.] 

Renal Tumors. — A tumor in the loin may be due to hy- 
dronephrosis, a very rare condition in a child; to a saccu- 
lated abscess in a scrofulous kidney; to an abscess around 
the kidney, either connected with spinal disease, or of renal 
or peri-nephritic origin, or to a sarcomatous growth of the 
kidney. 

Hydronephrosis is so rare that one is justified in passing 
it by. The scrofulous kidney has already been described, 
and there remain only peri-nephritic abscesses and new 
growth's. As regards the former, the presumption is in 
favor of spinal disease, and a careful examination of the 
spine should be made to establish the presence or not of 
any local disease ; but it is not always so. Extensive col- 
lections of pus may form around the kidney, which, if opened 
and drained, are speedily cured. In such cases the tumor 
is deep-seated and immovable, often ill-defined, from the 
presence of the colon in front of it. There is generally a 
good deal of pain, and some rigidity or flexion of the hip 
from implication of the origin of the psoas muscles, or pres- 
sure upon nerves. I have lately had a case of this kind in 
a child of about seven. Mr. Lucas explored, and then 
opened and drained, a large abscess, and the child was well 
within a week or two. In such cases, generally of doubtful 
nature at first, we must watch carefully for the formation of 
fluid, and — should evidence be found of its existence — ex- 
plore with a fine aspirator, and act according to the result. 
If pus be present, an opening should be made in the lumbar 
region, and the abscess drained. 

New Growths. — These are chiefly sarcomata. They are 
not very uncommon. I have seen five cases. Like all 
tumors in early life they grow rapidly, and ultimately pro- 



450 THE DISEASES OF CHILDREN. 

duce an enormous distension of the abdomen. They are at 
the onset, and remain for some time, unilateral, for which 
reason they are most favorable cases for operation. But 
when they have been long in existence, and have attained a 
large size, secondary nodules may be found in the other 
kidney or in the lungs, etc. They grow for some time with- 
out attracting much attention, for they are not associated 
with much wasting ; they are unattended by pain, and they 
are not, so far as I have seen, generally accompanied by 
haematuria. Thus it happens that not till the abdomen — 
and, therefore, the tumor — attains a large size, is the child 
brought for treatment. 

They occur in quite young children of eighteen months 
to three or four years old, when the removal of a mass so 
large is necessarily a most formidable operation. But, if 
they should be recognized sufficiently early, considering that 
they are usually local tumors and certain to prove fatal if 
let alone, then removal may be attempted. Of the five cases 
to which I have alluded, three have come under my own 
notice, and tw r o under the care of my colleague. In one of 
my own the removal of a very large tumor was attempted 
by Mr. Howse in a boy of two years, and had to be aban- 
doned, a result for which we were prepared ; in another case 
under Mr. Howse the tumor was removed, but the child died 
very soon after the operation, also a result for which one 
must be prepared if the operation is to be undertaken at all ; 
and in a third case, also under Mr. Howse, the tumor was 
removed, and the wound healed, but the child afterwards 
died of measles. Of the other two, one died, after many 
weary months of gradual emaciation, and one still lives — 
the parents, with whom alone a decision so momentous must 
rest, being unable to decide whether they will risk an ope- 
ration. 



DISEASES OF THE GENITOURINARY ORGANS. 45 I 

Nocturnal Incontinence of Urine, or Enuresis. — There 
are few conditions which require more careful investigation 
than this, and few in which such a variety of circumstances 
may conspire to bring it about. Granting that it depends upon 
a nervous fault, the results of treatment would seem to show 
that sometimes it is due to hyper-sensitiveness of the centre, 
sometimes to deficiency of the natural delicacy of perception 
either on the part of the lumbar cord or the higher centres 
to which it should transmit its own knowledge. 

How many other considerations also does the disease 
entail ? In some cases the constitutional build of the 
patient must be considered ; the sleeping habits of the ner- 
vous system ; the question of developing sexual sensation ; 
the condition of prepuce, urethra, rectum ; the possibility 
of the existence of local disease; the presence of ascarides; 
and, in confirmed cases, the question of habit. The mere 
mention of all these things w 7 ill be sufficient to show that 
whoever will treat enuresis with success must be prepared 
for a preliminary inquiry of a somewhat complicated 
nature. 

After saying thus much, it will not be expected that I 
should advise the reader to hit out at random with bella- 
donna, or bromide of potassium, or chloral. Each case 
must be investigated carefully, and treated accordingly. If 
there be any phimosis, this must be attended to, not neces- 
sarily by an immediate circumcision, but at any rate by 
retraction, separation of any existing adhesions, and the 
removal of any retained secretion that may be present. 
Circumcision is a useful thing, if there be reason to suppose 
that the length of the prepuce or the tightness of the phi- 
mosis is a disposing cause. Local congestion, perhaps due 
to constipation or to the presence of worms, must be ex- 
amined for. In other cases the tone of the nervous system 
is at fault, and during the night there is a general or local 



452 THE DISEASES OF CHILDREN. 

erethism of the nervous centres which leads to this spas- 
modic discharge. This state of the nervous centres is 
sometimes constitutional and closely associated with rheu- 
matism. In this case it goes with, or is allied to, such ner- 
vous disorders as nightmare, somnambulism, possibly even 
epilepsy. In other cases this nervous erethism is depen- 
dent upon sensations which have their origin in the devel- 
oping sexual centre, and unquestionably there is a form of 
nocturnal incontinence which replaces the seminal emissions 
of the mature organism. Allow this, and how complex 
the question becomes. Sometimes there is the low tone 
and in-bred sensation ; sometimes the sensations may be 
called into being by external circumstances, such as a too 
hot or too comfortable bed ; sometimes, may be, there is 
some local peripheral excitement, a long prepuce, or an 
over acid urine, for example. In some children, again, it 
seems that sleep is too sound, and secretion too rapid; and 
the reflex centre, uncontrolled, acts in accordance with its 
natural habit, and the urine is passed into the bed. 

Thus, in enuresis, very much the same questions come 
over again that have already been discussed in connection 
with the gastro-intestinal derangements of infants. A little 
physiological reflection, if it does not make the whole sub- 
ject clear, at any rate leaves one with the comfortable 
opinion that he knows something about it, and with defi- 
nite aims in the treatment of a somewhat mixed class of 
cases. 

Of thirty-eight cases, twenty were girls and eighteen boys. 
The favorite age is about seven ; but twenty-seven of the 
thirty-eight occurred from six to eleven years ; seven others 
at three and four years of age. Eight occurred in rheu- 
matic families. 

The treatment of these cases justifies all that I have 
said. There are some which are cured off-hand by bromide 



DISEASES OF THE GENITOURINARY ORGANS. 453 

of potassium and hydrate of chloral, just as infantile con- 
vulsions and night terrors are almost certainly controlled ; 
there are others as certainly controlled by belladonna, 
which not only heightens arterial tension and thus tends to 
restore the nervous tone, but also has some paralyzing effect 
on the afferent nerves, while it is well known to control what 
is, as I have maintained, the allied condition of seminal emis- 
sions. There are other cases best treated by good nervine 
tonics, such as strychnia and dilute phosphoric acid. 
Others, those of heavy sleepers, must be less luxuriously 
housed. Others, again, of rheumatic tendency, may be 
passing a highly acid urine, which irritates the bladder and 
provokes expulsion; this may be remedied by cutting off all 
meat from the diet for a week or ten days, and adding some 
bicarbonate of potassium to the food. In all cases a better 
habit should be favored, by restricting the quantity of 
drink towards the end of the day, and by arranging that 
the child is taken up to pass water late at night, early in 
the morning, and, if necessary, once during the night. In 
all cases the general health must be looked to, and tepid 
and cold bathing be practiced when possible. 

Occasionally, the incontinence is not only nocturnal but 
occurs during the day also. The affection is sometimes in 
such cases a part of an imbecile condition, and in rare cases 
the faeces are evacuated involuntarily also. When daily as 
well as nightly, they are likely to be very intractable, and 
are cases for a very careful examination of the pelvic organs 
under chloroform. It may be that, by long persistence of 
the habit, the bladder has become so contracted as to be 
incapable of holding any quantity of urine, and in such 
cases I have once or twice found it necessary to distend the 
bladder by injecting water, under chloroform. 

In any case, long persistence in the habit will necessarily 
make the case obstinate. For our comfort we may remem- 



454 THE DISEASES OF CHILDREN. 

ber the usual doctrine, that such cases generally ameliorate at 
puberty; but it may also be said that, in proportion as an 
early and intelligent appreciation of the problem is brought 
to bear upon an individual case, so is it likely to prove trac- 
table. Intractability is the recompense of an indolent and 
undiscriminating administration of belladonna or whatever 
comes to hand. 

Calculus Vesicae only needs mention as a complaint of 
which the diagnosis frequently falls upon the physician. I 
am under the impression that during the years that I saw 
out patients at the Evelina Hospital, the majority of cases 
of calculus were sent into the hospital by me, at any rate 
five such cases occurred. The symptoms are pain in mictu- 
rition, frequent micturition, stoppage in the flow of urine, 
uneasy sensations after emptying the bladder — worse when 
moving about, the occasional presence of a little blood in 
the urine, of pus or mucus in excess more frequently, and 
incontinence of urine. 

Diagnosis. — Many things simulate stone — e.g., rectal 
worry by worms or polypus; penile worry — e.g. a long or 
adherent prepuce; disease of the kidney or bladder^ and, 
in the female, vaginal discharge, etc. 

Vaginal and Labial Discharges are due to some eczema 
of the external parts, or to some catarrhal state depending 
on the presence of worms or to ill-health in scrofulous or 
tubercular children. 

Treatment. — At first this may be confined to plenty of 
bathing and to tonics, such as the lacto-phosphate of iron 
and cod-liver oil. If worms are present, they must be 
attacked by enemata or aperients. Later on, the vagina 
may be syringed with a lotion of lead or salicylic acid. 

Noma* is so rarely seen that it may go undescribed. 

* Noma pudendorum. — Ed. 



DISEASES OF THE NERVOUS SYSTEM. 



455 



CHAPTER XXXII. 



DISEASES OF THE NERVOUS SYSTEM. 



Inflammation of the Dura Arachnoid is dependent, as in 
adults, upon injury or disease of the bones of the skull. It 
is comparatively rare, and causes no special symptoms other 
than will be considered as those of meningitis. Meningitis 
is, indeed, usually associated with it; and one hardly meets 
with those more chronic forms of disease, or pachymenin- 
gitis, that are met with in adults. As a rare instance, how- 
ever, of something of the kind, the first of the cases which 
follow may be given. The second case, while it illustrates 
the occurrence of local collections of pus in the arachnoid, 
also illustrates the liability which exists for a general 
meningitis to be set up under those circumstances. 

A boy, aged four and a half, was admitted under Mr. 
Birkett in 1874, for a swelling in each upper eyelid. Twelve 
months before his admission his left eye began to swell ; a 
month later the other eye did the same, and for three weeks 
before admission he had been very drowsy. He was admitted 
for the tumor over the left orbit, and it was then noticed that 
there was a hard cartilaginous body, freely movable under 
the skin, beneath the margin of the left orbit. His sight was 
unaffected, and the movements of the eye-ball were perfect. 
His temperature ran up to 104 and 105 ° within a day or 
two of admission, and he died of pyaemia. 

At the autopsy, the history of the case appeared to be 
this : There had been caries of the first lower molar and 
abscess; then suppuration in the inferior dental canal, acute 
ostitis of the left side of the lower jaw, extension of the dis- 



45^ THE DISEASES OF CHILDREN. 

ease in the pterygo-maxillary fossa, and thence to the base 
of the skull. Having entered the skull by the foramina at 
its base, and having thickened and dissected up the dura 
mater from the base of the skull in the middle fossa and 
about the body of the sphenoid bone, it had entered each 
orbit, treated the periosteum of those cavities in like man- 
ner, and the tumor in the left orbit was in reality only a 
tough yellow mass, of inflammatory origin. 

A female child of six months was brought for wasting of 
three weeks' duration. She was emaciated and pale, the veins 
of the head were distended, and the fontanelle, lj& X 1^2 
inches, was bulging and pulsating. There is no note of any 
paralysis, but there were soft, elastic, tender thickenings over 
the lower halves of the right radius and ulna and left hume- 
rus, a state of things which, at this distance of time (nine 
years), sounds very like syphilitic disease of the bones, 
though it does not appear to have occurred to any of those 
who saw the case, myself amongst the number, to call it so. 
The child died with convulsions. 

At the autopsy, a large collection of pus was found be- 
tween the dura mater and the right side of the brain. It 
extended from vertex to base, and from the anterior part of 
the middle fossa back to the horizontal branch of the lateral 
sinus. It did not enter the cerebellar fossa. Its wall was 
ochre-yellow, like a typhoid stool, but the pus itself was 
" laudable." Pus occupied the ventricles. The lateral sinus 
was plugged on both sides, the left by clot of older date than 
the right. There was no disease of the internal ear. The 
bones were slightly rickety. 

A condition such as this is probably more often produced 
by disease of the bones of the internal ear, and careful search 
for such should be made at the post-mortem examination ; 
but it may occur from pyaemic conditions, from the exten- 
sion inwards of erysipelas, or from unhealthy inflammation 



DISEASES OF THE NERVOUS SYSTEM. 457 

of the bones of the scalp and of the pericranium, and occa- 
sionally, also, in the absence of all but emaciation the dis- 
ease may have originated spontaneously. 

Intra-arachnoid hemorrhage and pachymeningitis have 
been described by most writers, but such conditions are of 
rare occurrence, and are not peculiar to childhood ; they will 
not therefore be further mentioned here. 

I must, however, call attention to the fact that, in young 
children, pressure upon the surface of the brain, whether by 
hemorrhage or pus, as illustrated by the cases of arachnitis 
already recorded, seems less liable to cause paralysis than 
might have been imagined. Surface hemorrhage or pressure 
is more likely to produce stupor with feeble circulation and 
death either by convulsions or exhaustion, and this is a point 
of importance in diagnosis. 

Simple Meningitis (Lepto-meningitis, suppurative menin- 
gitis) is probably a disease which is more common than has 
been supposed. Tubercular meningitis is more so, but there 
has been too great a tendency to sweep all forms of menin- 
gitis of childhood into the net of tubercle than is justified by 
the facts of post-mortem examination. I have notes of forty- 
one post-mortems of cases which without an examination 
w r ould have been set down as tubercular, but eight of them, 
or one-fifth, were simple ; and in a most valuable paper by 
Drs. Gee and Barlow, in the " St. Bartholomew's Hospital 
Reports" for 1878, " On the Cervical Opisthotonos of In- 
fants/' six cases are given, in which a post-mortem demon- 
strated the absence of tubercle and the presence of simple 
basal meningitis. Cause for acute meningitis is to be found 
abundantly in disease of the ear and nose, and in the acute 
exanthems and many other febrile states that are met with 
at this time of life. Simple meningitis is said to be developed 
by preference at the convexity, and has therefore been called 
by some meningitis of the convexity ; but a non-tubercular 



458 THE DISEASES OF CHILDREN. 

basal meningitis is far from uncommon, and the fact that the 
convexity is also often attacked is probably due to the dis- 
ease being so often an extension from disease elsewhere — or 
secondary, as it is called — but even then it is liable to extend 
all over the surface and even into the ventricles. The brain 
is usually covered with a layer of yellowish or green pus, 
and the same kind of material may be found in the ventricles, 
and, if the case be in any degree prolonged, I have seen the 
lining membrane of the ventricles of a rose-pink color from 
minute injection, and villous-looking or velvety from inflam- 
mation. The pus may also be found to extend down the 
cord in quantity, where it will mostly appear on the posterior 
aspect, having evidently gravitated to that position. There 
is no distinction, such as is sometimes made between men- 
ingitis of the brain and that of the cord. The membrane 
affected is one and the same, and disease of the membranes 
of the brain runs with perfect facility along those of the cord. 
In some cases the inflammation appears to be shut off about 
the foramen magnum, but this I imagine is rather an acci- 
dent than anything else. 

Simple meningitis appears to be a disease of infancy rather 
than of childhood. 

The symptoms are often indefinite, although the course of 
the disease (I have known it to last a month) may be rapid ; 
and if we may accept cervical opisthotonos as evidence of 
meningitis, it may not only be very chronic but also remit- 
tent. The child is pale, with retracted head and much scream- 
ing if moved; its abdomen is retracted, the bowels confined, 
and it takes food badly. There may be fever, rigidity of 
limbs, convulsions, vomiting, and, in very chronic cases, 
hydrocephalus. The symptoms appear to depend somewhat 
on the age of the child — in infants I notice a tendency to 
collapse, with restlessness, swelling of the head, enlargement 
of the veins of the surface, and retraction of the neck ; in 



DISEASES OF THE NERVOUS SYSTEM. 



459 



older children there is more fever, and definite evidence of 
meningitis in headache, vomiting, irregularity of pulse, and 
squint. 

The disease is met with after injury — otitis (externa or 
interna), ozaena, excessive mental effort in children at school ; 
it may occur also after some acute illness, such as scarlatina, 
erysipelas, or nephritis, and it has been noticed as one of the 
results of the pyaemic condition found in new-born children 
from inflammation about the umbilical sore. Of the two 
cases which follow, one exemplifies the occurrence of menin- 
gitis after injury; the other after otitis interna. 

A previously healthy male child, aged seven months. 
The mother fell with it in her arms a fortnight before it was 
brought to the hospital. Ever since then it had held its 
head back, screamed much at any attempt to move it for- 
ward, and the head had swelled considerably. It had not 
vomited. Its bowels were confined; it had a sallow pallor; 
its temperature was normal; the pulse quick, but regular; 
and the neck retracted. There was no rigidity of limb. It 
lay nearly insensible, with retracted pupils, retracted abdo- 
men, and in a collapsed state; the tongue being furred and 
dry, and no food being taken. It died shortly afterwards. 

At the autopsy, the viscera were all healthy, except the 
brain. The latter was congested, dry on the surface, and 
the convolutions pressed together. A little pus-like lymph 
was found at the base, and here and there on the convexity. 
The ventricles contained seven or eight ounces of turbid 
sero-purulent fluid, and they were widely dilated. Their 
ependyma was thick, woolly, velvety, and patched with pu- 
rulent lymph. In the posterior cornu of the left ventricle 
was a local collection of 5iij of pure pus. The brain was 
soft ; the cord normal ; rather adherent at the foramen mag- 
num. There was no disease of ears or sinuses ; and, so far 



460 THE DISEASES OF CHILDREN. 

as could be detected, nothing whatever to account for the 
disease but the blow received some weeks before death. 

A girl of seven had been ailing for a month, and deaf in 
the right ear ; there had been no discharge. Subsequently 
there was high temperature, retracted neck, and strabismus. 

The autopsy showed general suppurative meningitis, sup- 
puration of the middle ear, on both sides, extending to the 
bone, and points of pus appearing on the internal table in 
many places. The membrana tympani was sound on both 
sides. I subsequently traced the suppuration along the 
bony part of the Eustachian tubes. There was chronic en- 
largement of one tonsil. 

The diagnosis will in most cases be difficult. In young 
children the symptoms of meningitis are often obscure, and 
marked by an absence of those most characteristic ; but 
when the diagnosis of meningitis is arrived at, there comes 
the further question, is it tubercular or not? 

I have known two of the most distinguished and expe- 
rienced physicians differ as regards the nature of a case of 
meningitis — one thinking it tubercular, the other not. The 
case in question turned out to be non-tubercular; but the 
reason of the successful diagnosis it would be hard to give. 

In infants retraction of the neck should excite attention, 
and any rigidity of the neck or pain on movement. The 
other signs of meningitis must then be carefully sought, such 
as rigidity of the muscles elsewhere, evidence of pain in the 
head, swelling of the head, distension of the veins of the 
scalp, vomiting, retraction of the abdomen, constipation, 
irregularity of pulse, a tendency to reddening of the skin 
upon slight irritation [tache cerebrate), and the state of the 
fundus oculi. 

In all children the previous health must be taken into 
account — the pre-existence of measles, scarlatina, sore 
throat, earache, and so on ; the existence also of pyrexia, 



DISEASES OF THE NERVOUS SYSTEM. 46 1 

intolerance of light, headache, etc., may, any one of them, 
help on occasion. 

In meningitis there is no symptom which is infallible ; 
there are no two or three which will not sometimes play us 
false ; but the most reliable are, retracted head, fever, cause- 
less vomiting, irregularity of the pulse, and muscular rigid- 
ity, or weakness. 

Prognosis is very unfavorable ; nevertheless, when we look 
over the notes of cases of hemiplegia, muscular rigidity and 
wasting, feeble intellect, apoplexy, and various other nervous 
disorders which occur in children, a fair proportion of these 
seem to originate in symptoms which cannot be distin- 
guished from those of meningitis. Nay, more than this, 
scattered throughout hospital reports are notes of cases 
which have been considered to be meningitis, but in which 
that diagnosis has subsequently been rendered doubtful, or 
thrown over, because of the recovery of the patient. 

An impartial consideration of cases of this kind leaves very 
little doubt that the original diagnosis, at any rate in some, 
has been correct, and that what has really been the error has 
been the too rigid application of the more general rule that 
meningitis is generally fatal. 

No doubt some of the less severe cases of simple menin- 
gitis get well. With a case fresh in my memory, under the 
care of my colleague, Dr. Taylor, recovery might indeed 
never seem hopeless. For weeks a child of about two years 
old lay, apparently blind, with retracted neck, and to all 
appearance dying — its powers were so feeble and the nour- 
ishment taken so little; yet it lived on, and no doubt was of 
robuster material than we gave it credit for, for a subsequent 
attack of scarlatina did not prove an extinguisher, and now 
it is in good health. 

We must endeavor to extract our hope from any symp- 
toms which may suggest the localization of the mischief and 

39 



462 THE DISEASES OF CHILDREN. 

the possible absence of suppuration. If the disease be of a 
purulent nature, from scarlatina or chronic disease of the 
ear, etc., recovery can hardly be expected. 

Treatment. — It is the fashion to give iodide of potassium 
in these cases, and, although it is seldom that any good 
results, yet, in the hope that some inflammatory material 
capable of absorption may be present, the practice may as 
well be continued. I give it, and often small doses of calo- 
mel, or the hyd. c. cret. as well. 

Counter-irritation and shaving the head are advised. Both 
are objectionable, and apparently useless. An ice-cap to the 
head will do all that is necessary, although of this also it 
must be said that no great value can be demonstrated, never- 
theless it should be used, and used vigorously and contin- 
uously. 

Quinine is another remedy which may be given if the 
temperature be high ; and in all those cases in which a pos- 
sible poison is at the bottom of the disease, it is well to 
remember that we may, in the future, and by careful trials, dis- 
cover something which shall destroy it, and, therefore, new 
drugs of the germicide class deserve a careful trial when 
introduced. 

Any violent delirium must be controlled by bromide of 
potassium, chloral, Dover's powder, or the succus hyos- 
cyami. 

In the more chronic cases, careful feeding is a great ne- 
cessity. There may be some difficulty in swallowing, and 
the bodily conditions are such that any slight broncho-pneu- 
monia is too likely to prove fatal. Particular care must be 
enjoined in giving the food to see that no more is given than 
can be readily swallowed, and that the position be such that 
swallowing is made easy. To see a child lying flat on its 
back, and the food tilted in at the angle of the mouth by 
gushes, is to foretell a spluttering and insufficient meal, 



DISEASES OF THE NERVOUS SYSTEM. 463 

and the probable termination of the case is broncho-pneu- 
monia. 

Given a case of recovery from the immediate disease, the 
resulting muscular rigidity must be treated by gymnastics, 
faradization, massage, etc. 



464 THE DISEASES OF CHILDREN. 



CHAPTER XXXIII. 

TUBERCULAR MENINGITIS. 

Tubercular Meningitis is sometimes called basilar, be- 
cause it so frequently and chiefly occurs at the base ; acute 
hydrocephalus, for far less definite and explicable reasons — 
at any rate, effusion of fluid is no prominent feature in the 
result. 

Tubercle attacks the brain in two ways — as a diffused and 
more or less acute granular inflammation of the membranes, 
and as a local disease in the form of a yellow mass or tumor. 
For some reason, not easy to give, the tubercular tumors 
are more often situated in the cerebellum or pons. These 
two forms may be found separate or associated, and every 
now and again intermediate conditions are met with which 
make it impossible to separate the two. 

For instance, in the Sylvian fissure, perhaps, the grey 
tubercle may be unusually abundant, and the individual 
granulations large. Some of them maybe distinctly yellow. 
Sometimes the granules reach the convexity, and, massing 
themselves into a yellowish layer, spread over the surface of 
some of the convolutions ; sometimes small yellow nodules 
are scattered over the brain in the depths of the sulci, and 
are found on making vertical slices of the cortical structure. 
The appearance of the tubercular nodule is worth noting; it 
is invariably surrounded by a grey, gelatinous zone of soft 
vascular material, very similar to the grey, gelatinous mate- 
rial sometimes seen in cases of pulmonary tuberculosis. This 
is the growing tubercle. There is, therefore, in the brain 
an exact counterpart of pulmonary tuberculosis in all its 



TUBERCULAR MENINGITIS. 465 

stages, even to that of the chronic disease being a frequent 
cause of acute miliary tuberculosis of the part, or of tuber- 
cular meningitis. 

The brain is usually soft, the central parts may be almost 
diffluent, in tubercular meningitis, and there may be, usually 
is, a slight excess of cerebro-spinal fluid at the base and in 
the ventricles ; but this excess is, as I say, no striking fea- 
ture, and hardly warrants such a confusing term as acute 
hydrocephalus. Occasional conditions — such as patches of 
red softening or acute encephalitis, punctiform hemorrhages, 
or even, though very rarely, a large extravasation of blood — 
may be met with, either in relation to a growing tubercle 
or to some secondary thrombosis of one of the vessels. 

As regards the spinal cord, it is no uncommon thing to 
find it affected in the same way as the base of the brain. It 
follows the rule I before laid down, that there is no distinc- 
tion between the two parts. The affection is not always 
present ; occasionally it may be spinal and not cerebral, but 
it is very commonly both. It is very important to remember 
this in a disease of so insidious an onset as tuberculosis ; 
there are cases in which the symptoms are chiefly spinal, 
such as general hyperaesthesia, muscular and other pain 
simulating joint disease, or the pain in the neck and retrac- 
tion of the neck already alluded to in simple meningitis. 
These things are explained by the spinal affection — or may 
lack any other explanation — in the absence, and frequent 
absence, of cerebral symptoms. 

One other point, which has of late been made much of, is 
the frequency of the existence of tubercle of the choroid. 
Dr. Angel Money found that in forty-two cases of tubercular 
meningitis choroidal tubercle was present in fourteen ; in 
two others it was present, once with a tubercular mass in 
the cerebellum, once without any cerebral tubercle of any 
kind. 



466 THE DISEASES OF CHILDREN. 

The histology requires little mention, it is almost beside 
the purpose of this book ; but the details of tubercle may be 
well worked out in the pia mater, and perhaps better than 
in other places, in some respects, for here of all parts it has 
such a plain association with the peri-vascular sheaths. The 
giant cells and reticulum are generally well seen. As re- 
gards the presence of the bacillus tuberculosis in these cases, 
further investigations are wanting. I have several times 
failed to find it in cases of pure miliary tubercle of the pia 
mater — that is, in cases in which no softening or degenera- 
tive changes had occurred. 

As regards its association with disease elsewhere, it seems 
to me that cheesy bronchial glands and a subsequent dis- 
semination of miliary tubercle in the lungs, viscera, and pia 
mater is by far the most frequent occurrence. But it is 
found with other conditions also, such as disease of the 
spine or chronic disease of the bones and joints. It may, of 
course, be found with a chronic phthisis, or with mesenteric 
disease, although these and other conditions appear to me 
to be far less frequent. If the cases of tubercular menin- 
gitis spreading from yellow masses in the brain itself, to- 
gether with those in which it is secondary to caseous disease 
of the mediastinal glands, and those in which it is due to 
chronic bone disease, be subtracted, I think that the re- 
mainder, whether from scrofulous kidney, chronic phthisis, 
tabes, etc., would form a very small proportion of the total. 
The amount of disease in the glands is, of course, variable. 
It may be confined to the mediastinal glands, or it may infect 
those above and below the thorax, and even those in other 
parts ; and, in the same way, the accompanying disease in 
the viscera is very variable — the liver, spleen, and kidney 
may look quite natural, except a scattered distribution of 
small grey grains with ill-defined margins visible beneath 
the capsules ; or there may be larger nodules, either in 



TUBERCULAR MENINGITIS. 467 

spleen or liver, becoming cheesy. In the kidney the nod- 
ules increase, not so much by a circumferential addition as 
by running downwards in a streaky way towards the pyra- 
mids. All three of the solid viscera are in some cases 
affected by an infiltration rather than a nodular growth, 
when they increase much in size and put on a peculiar 
mottled appearance, which is strikingly abnormal. The 
liver is not infrequently studded with nodules of some size, 
which on section show a dilated bile duct, containing often 
retained and perhaps inspissated bile. Tubercle in the liver 
runs along the portal canals, and thus comes to surround 
the biliary canals, and there is this practical import attach- 
ing to it, that tuberculosis in a child is sometimes attended 
with moderate jaundice. Softening of the stomach has 
been described as a frequent lesion in tubercular meningitis. 
I have never observed any such change myself, or one that 
could not be ascribed to simple post-mortem solution. 

The disease may occur at any age. Of thirty-three 
deaths, one occurred at three months, three at six months, 
one at nine months, three at twelve months, four under two, 
three under three, six under four, four under five, one under 
six, four under seven, and three at eight, ten, and twelve 
respectively. 

The course of the disease averages three weeks, but it 
may be rather more prolonged and is occasionally much 
shorter. The duration is, however, difficult to fix ; for, as 
with the earlier days of typhoid fever, the onset often passes 
without recognition. 

Symptoms. — Malaise, wasting, bad appetite, restless nights, 
disturbed by startings and a harsh, painful, short cry, bad 
dreams, pain in the head, confined bowels, and some irregu- 
larity of pulse. The child is usually paler than natural, but 
apt to flush suddenly with an unnatural flush. These are 
the symptoms of the onset, and, as needs no saying, they 



4 6 3 THE DISEASES OF CHILDREN. 

are so indefinite as to give very little help. With such 
symptoms as these only, one is in danger either of being 
too foreboding, and of condemning many to tubercular 

meningitis when there is s:me heeting gastric disturbance, 
or else c: treating as trifling what will end in speedy death. 
Nevertheless, things can hardly be stated more definitely. 
As the disease matures the cerebral excitement becomes 
more intense, and the special senses suffer exalted sensi- 
bility. Thus it is that the child avoids the light, starts at 
sounds, and cries if disturbed by movement- The symp- 
toms now are vomiting, retraction of the abdomen, intoler- 
ance of light, fever, general hyperesthesia, stiffness of the 
neck or other muscles, irregular, and sometimes well- 
marked Cheyne-Stokes', respiration, strabismus, convul- 
sions, coma, and a pulse which becomes very rapid. 

It is usual to describe tubercular meningitis as a disease 
of stages. The first, of brain irritation, in which headache, 
vomiting, constipation, retracted abdomen, quick irregular 
pulse, excitement, delirium, and convulsions are the chief 
symptoms ; : id, of brain pressure, with pupil symp- 

toms, coma, facial or other local paralysis, hemiplegia, and 
slow pulse, in addition; and in the third, the paralysis :> 
creased and me general, the pulse again quickening, and 
becoming running, the temperature perhaps falling, but the 
coma continuing. But the difficulties of the student lie in 
the stages being confused ; in many of the symptoms being 
absent Nor is the teacher much better off; for added 
experience only makes it increasingly clear to him how 
treacherous is this disease, and how impossible in some 
cases it is t : mistakes Nevertheless, a careful watch 

of a suspected child will do much towards replacing doubt 
by certainty. 

The child that is hatching tubercular meningitis not only 
wastes and loses appetite, and becomes pale, but he often 



TUBERCULAR MENINGITIS. 469 

changes in disposition, and becomes cross or fretful, with 
frequent complaint of his head or of being tired. lie will 
show a dislike to all noise; perhaps he will walk with care, 
as if his neck were stiff, or totteringly. There may be some 
slight tremulousness of his arms, an irregular twitching, such 
as one sees from other causes, sometimes in uraemia. As 
the disease progresses, there is a causeless vomiting, uncon- 
nected with feeding, and irregular in its onset. The later 
symptoms are more headache, perhaps drowsiness or stupor, 
a high temperature, though usually an oscillating one, and, 
in the paralytic stage, there may be either general convul- 
sions, tonic spasm of one arm or the other — or of both legs, 
or the whole of one side — or clonic convulsion. The pulse 
may be slow after the first onset, but usually rises again as 
death approaches. 

When convulsions come on the fatal termination is not 
usually long delayed. The case may drag on for three 
weeks or so in an indefinite way, and the marked cerebral 
symptoms, either convulsions or coma, be not more than 
two or three days in duration ; and there are cases in hos- 
pital practice where the prodromal stage has been altogether 
overlooked. The child is perhaps brought for convulsions, 
which have ushered in the final stage, and death occurs 
within a short time of admission. Local paralyses are not 
uncommon particularly of the sixth and facial nerves. Pa- 
resis of arm or leg, or of both, is common, but complete 
paralysis is rare. 

In young children, before the fontanelle has closed, there 
may be bulging, the surface veins may be distended, and 
there may be evident head pain denoted by the restless 
knocking of the head with the hands, or, when asleep or in 
its cot, by the frequent harsh encephalic shriek which is so 
painful to the hearer. 

The optic discs should in all cases be carefully examined 

40 



470 THE DISEASES OF CHILDREN. 

for changes at the fundus. But in the majority of cases . 
these are not marked, and would pass unrecognized by any 
but the most skilled observers. There is even a difference 
of opinion amongst those most competent to form an opinion 
— some averring that changes may be seen in many cases, 
others that they are exceptional. The morbid changes are 
of two kinds : i. Evidences of swelling and inflammation ; 
2. The presence of choroidal tubercle. The latter is unques- 
tionably rare. As I have already said, there is every proba- 
bility of tubercle existing in the choroid, either as minute 
grains, to which Dr. T. Barlow has applied the term tuber- 
cular dust, after Rilliet and Barthez, or in larger tubercles, 
but which pass unrecognized during life. But to be able to 
be sure of the presence of tubercle in the choroid by an 
ophthalmoscopic examination is certainly the rare excep- 
tion. It is more common by far to be able to detect some 
increase in size or tortuosity of the veins, some alteration of 
the vessels from day to day, some swelling of the disc, some 
slight cloudiness of the edge, or lymph-like grains about its 
edge, which tend to obscure the vessels from view. Of the 
frequency of these appearances there must of necessity be 
different opinions; of their value if present, some latitude 
must also be allowed to individual observers. The opinion 
will necessarily depend upon how much range is allowed 
for the variations in the appearances of the normal disc. In 
my own cases, however, I may say that pronounced changes 
of any kind have been quite exceptional. For a statement 
on the other side, it may be said, that Dr. Garlick, in some 
observations made in the Ormond Street Hospital, found 
them in 80 per cent, of the cases.* 

The Temperature chart of tubercular meningitis is likely 
to show considerable excursions. Qf twelve cases, it was over 

* "Med.-Chir. Trans.," vol. lxii., p. 441. 



TUBERCULAR MENINGITIS. 47 I 

105 ° in three, and in a fourth ran up to that height at death. 
In two others it went to 104 . In three it was not over 100.5 . 
The oscillations are often considerable ; even as much as 
three or four degrees. The highest point reached daily is 
irregular; sometimes it is in the morning, sometimes it is 
high both night and morning, sometimes one day at night 
and another in the morning. 

Of the many symptoms, some are more reliable than 
others. Of these are, irregularity of pulse and respiration, 
vomiting, for which no cause can be assigned, intolerance of 
light, headache if accompanied by retracted abdomen, stiff- 
ness of the neck, and hyperaesthesia of the surface. Strabis- 
mus and convulsions are, of course, equally reliable in their 
place ; but they usually come at a time when doubt is giving 
place to certainty. 

Diagnosis. — Typhoid fever is the great difficulty; in it 
even strabismus has been known to occur, as if to make the 
symptoms of the two diseases exactly similar. If, after pay- 
ing all attention to the previous history and surroundings 
of the patient, there is still doubt, one must withhold one's 
judgment. Retraction of the abdomen, hyperaesthesia, and 
irregularity of the pulse, are here especially valuable indica- 
tions. Vomiting fails, as it may be present and severe in 
typhoid ; still, in meningitis, it is usually erratic rather than 
of the urgency of a typhoid condition. Constipation is of 
little value, it is so often present in typhoid fever; but it and 
retraction of the abdomen are not common together. The 
splenic enlargement sometimes gives a hint. The tache cere- 
brale is found under such a variety of conditions as to be of 
little use. 

From simple meningitis, in the absence of any local source 
for that affection, it cannot be distinguished with any cer- 
tainty. I had thought that the temperature ran higher in 
simple than in tubercular meningitis ; but it does not appear 



472 THE DISEASES OF CHILDREN. 

that this is so on an appeal to facts. Simple meningitis is, 
however, likely to be more sudden in its onset, acute in its 
symptoms, and rapid in course. Steiner notes that it may 
sometimes require the greatest skill to distinguish between 
meningitis and chronic hydrocephalus. I have seen the 
mistake made. A case of hydrocephalus terminated in 
meningitis of a few days' duration ; but although the cere- 
bral symptoms were not unlike those of meningitis, yet the 
temperature was persistently low throughout the illness and 
until just before death. 

It may sometimes prove difficult to decide at the moment 
between tubercular meningitis and acute gastric disturb- 
ances. Attention must be given to the previous state of 
health — tubercular troubles maturing slowly, gastritis sud- 
denly. Moreover, the latter is wont to occur at the time of 
dentition, and to be associated with a foul tongue, whereas 
a tubercular meningitis is frequently ushered in by a clean 
tongue. 

Prognosis is as grave as it can be ; but instances of recov- 
ery are recorded, and, in this regard, we have frequent op- 
portunities of noting an important piece of evidence, for it 
often happens that yellow tubercle in the brain has obviously 
been where it is found a long time, and yet has caused no 
symptoms. We have evidence, then, that masses of tubercle, 
which have been slowly growing, may give rise to no symp- 
toms ; and that simple meningitis has repeatedly recovered. 
There seems, therefore, no reason why tubercular meningitis 
should not occasionally recover, and there is much evidence 
that it actually does so. Rilliet and Barthez, Meigs and 
Pepper, and Clifford Allbutt, all concur in the occasional 
occurrence of such cases. I believe that I have myself seen 
a case of the kind. We can hardly reach much more than 
the belief, because recovery precludes the verification, and 
there must always remain behind a doubt whether the case 



TUBERCULAR MENINGITIS. 473 

might not have been one of simple meningitis. But we may 
at any rate say that the facts are sufficient to justify us in 
affirming that the case is not absolutely hopeless. 

Treatment. — Iodide of potassium should always be given, 
in the hope that, under its use, the symptoms may possibly 
ameliorate. The liquor hydrarg. perchlor."* may also be 
given, in twenty- or thirty-drop doses, or more. It may act 
as a promoter of absorption of inflammatory products, and 
it is not a form of mercury which has any harmful action 
upon children. Here, also, I have of late been trying iodo- 
form internally, in quarter- or half-grain doses, in very young 
children, and increasing it cautiously, if necessary, to one 
grain or even more. As I have already said, it requires 
watching, as it occasionally makes them sick and ill. Cases 
of phthisis have done well upon it, but I have not seen any 
marked effect upon tubercular meningitis. 

The child should be kept in bed, and perfectly free from 
excitement of any kind. An ice-cap should be kept to his 
head ; the bowels acted upon once a day ; and any headache 
or sleeplessness mitigated by bromide of potassium, chloral, 
or opium. The diet should be highly nourishing and easily 
digested, in the shape of eggs, milk, jellies, custard, etc. 

Children with hereditary tendency to phthisis, or those 
who look tuberculous, should be carefully watched and 
guarded. In infants a tuberculous mother should not nurse 
her child, but let it be fed artificially or by a wet-nurse. It 
must be kept warm, live as much as possible in a dry air, 
with porous soil, and the development of its brain must be de- 
layed as much as possible by keeping it away from books. 

* Liq. Hydrarg. Perchlor., Br. P., contains ten grains each of perchloride of 
mercury and chloride of ammonium to a pint of distilled water. — Ed. 



474 THE DISEASES OF CHILDREN. 



CHAPTER XXXIV. 

HYDROCEPHALUS. 

Hydrocephalus. — I dismiss the term chronic hydroce- 
phalus, because it is misleading. Hydrocephalus has often 
been a bugbear with students, because of the difficulties 
which have been made to exist by a description of three so- 
called varieties — acute, chronic, and false hydrocephalus. 
Acute hydrocephalus has been accepted as synonymous 
with tubercular meningitis, but in the preceding chapter I 
have pointed out that the effusion is usually of subsidiary 
importance, it is so small in quantity. The diagnosis is not 
made by the evidence of excess of the cerebro-spinal fluid, 
but by the evidence of inflammation of the membranes of the 
brain. Cerebro-spinal fluid is often in excess, but the excess 
is mostly a moderate one, and there are many reasons for 
questioning the influence of the fluid in the production of a 
fatal result. But both in this and in simple meningitis, par- 
ticularly when of a more chronic form and associated with the 
formation of a large quantity of sero-purulent fluid, the ven- 
tricles may become somewhat rapidly dilated, and be so 
found at the post-mortem; and, probably, the younger the 
child the more likelihood will there be of this. 

False hydrocephalus is a perfectly distinct affair, and 
need no more be introduced into the subject, than when 
discussing coma or collapse it is necessary to call one form 
true uraemic coma, for example, and all others false ursemic 
coma. 

[The condition called " spurious hydrocephalus " may be 
met with in any of the wasting diseases of childhood, but is 



HYDROCEPHALUS. 475 

most common during the later stages of inflammatory diar- 
rhoea. It is a result of exhaustion. 

The symptoms are drowsiness, half-closed eyelids, sluggish 
and unequal pupils, pinched features, lived complexion, 
sunken fontanelle, subnormal temperature, rapid intermittent 
pulse, and irregular sighing respiration. The drowsiness 
gradually deepens into coma, and slight convulsions may 
precede death. 

False hydrocephalus may depend upon the slow circula- 
tion of impoverished blood through the brain, upon the 
formation of thrombi in the cerebral sinuses, and, according 
to Parot, on uraemic poisoning, the symptoms being often — 
in cases of diarrhoea, for example — associated with marked 
diminution in the secretion of urine. 

The main treatment is the use of stimulants, both inter- 
nally and externally.] 

Hydrocephalus is a disease which occurs under limited 
and definite conditions, and it is a disease which has fairly 
definite symptoms. As with all other diseases, these are 
sometimes less distinct than at others, and the diagnosis 
may be mistaken or doubtful ; but difficulties in diagnosis 
are not peculiar to it, it shares them with every other disease 
that can be mentioned. By hydrocephalus I understand an 
equable enlargement of the cavity of the skull by fluid within 
the cerebral ventricles, and by which it tends to become more 
globular. The globular shape is somewhat interfered with 
by reason of the union with the facial bones in front, but, 
wherever it is possible, bulging takes place — at the fonta- 
nelle, which becomes much increased in size, at all the su- 
tures, and at the roof of each orbit. Thus the breadth of skull 
increases from side to side, the frontal bones become pro- 
truded forward and expanded, the eyeballs are prominent 
and their axes divergent. Within the cranium the brain is 
converted into a cyst, the larger in proportion to the dilata- 



476 THE DISEASES OF CHILDREN. 

tion of the ventricles by the accumulated fluid. The cortex 
cerebri lies everywhere in contact with its case. A distinc- 
tion is made between external and internal hydrocephalus — 
in the one case the fluid being outside the brain, between 
the skull and it, and in the other internal. I shall allude to 
the external form presently, but now it will be sufficient to 
say that internal hydrocephalus is the common form, and 
I doubt whether the external should receive the name of 
hydrocephalus at all. Hydrocephalus, then, is usually a 
cystic expansion of the brain by fluid within the ventricles, 
so that, if we were about to remove the fluid by tapping, it 
would be necessary to pass through the skull or its mem- 
branous equivalent, the dura arachnoid, the pia arachnoid, 
and the grey and white matter of the cerebral cortex, to get 
at the fluid. 

The bones of the skull in such a case are usually thin, 
sometimes so thin that there may be craniotabes. The fon- 
tanelles and sutures are perhaps widely gaping or filled up 
more or less by the formation of Wormian bones. 

Morbid Anatomy. — The brain is more or less expanded 
into a loculated cyst by the dilatation of all the ventricles 
and the iter. In extreme cases the cortical layer becomes 
so thin that it is impossible to remove the brain without 
laceration. If this can be done, and the brain taken out with 
a sufficiency of fluid in the ventricles, the appearances at the 
base may be somewhat peculiar from the dilatation of the 
third ventricle and the infundibulum. A thin-walled trans- 
parent cyst is seen, upon which the optic nerves, corpora 
albicantia, etc., are perched. Sometimes the optic nerves are 
cedematous. The lining membrane of the ventricles may 
perhaps, be a little thickened, but its appearance is otherwise 
normal. These conditions are important, because they serve 
to explain one or two clinical facts. In the first place, the 
extreme swelling of the parts about the optic tract and the 



HYDROCEPHALUS. 477 

chiasma may serve to show why there should be, as there is 

sometimes, white atrophy of the optic discs and blindn 
The dilated condition of the fourth ventricle may explain 
how such cases sometimes die suddenly. The fourth ven- 
tricle is sometimes so much dilated that all the parts become 
stretched over it, and the circulation through the medulla 
and pons must almost necessarily be disarranged, and the 
nutrition of those parts be feeble. 

The morbid changes which lead to hydrocephalus are not 
many, and their action is easily intelligible. I will place 
them in what is, perhaps, their common order of occur- 
rence : 

(I.) Tumor about cerebellum, pons, or tentorium. 

(2.) Chronic inflammation about the medulla and cere- 
bellum, leading to adhesion about the margins 
of the foramen magnum. 

(3.) Congenital malformation. 

These no doubt act in one of two ways. They may press 
upon the veins of Galen and the straight sinus, or they may 
close the communication between the interior of the ven- 
tricles and the rest of the sub-arachnoid space. It might be 
thought that the pressure upon the veins, and the obstacle 
thus produced to the return of blood from the choroid plex- 
uses, would be a sufficient and readier explanation of all cases ; 
but it seems clear from the occasional occurrence of congen- 
ital malformation, or the post-congenital adhesion and block- 
ing of the aqueduct of Sylvius, that the mere closure of the 
ventricles is sufficient for the production of the affection. 
Others causes are mentioned, such as inflammation of the 
lining membrane of the ventricles, and true dropsy of the 
ventricles. Of the first, I think it may be said that it is very 
rare, except under circumstances such as I have given in a 



4/8 THE DISEASES OF CHILDREN. 

case of simple meningitis (p. 459). Meigs and Pepper think 
otherwise and state that in many cases the lining membrane 
of the ventricles is granular and much thickened. I have 
not found it so. They also state, in correspondence with 
this, that the fluid drawn off in these cases is frequently like 
the effusion in pleurisy or pericarditis ; but here, again, ex- 
cept in one acute case, I have seen nothing in the ventricles 
in these cases but natural-looking cerebro-spinal fluid. Hil- 
lier states that dropsy may occur from obstructed veins 
either from simple or pysemic thrombosis. This would be 
a form of disease of similar origin to that of other cases — 
viz., obstructed venous circulation ; therefore whether there 
is such a thing as spontaneous dropsy of the ventricles, apart 
from such a cause, must still be a matter of conjecture. 
Rickets is said by many to be a cause of this disease, but the 
evidence in proof of this derived from actual demonstration 
in the post-mortem room is very scanty. 

Of twenty cases, seventeen were in boys, three only girls. 
Their ages : two of three months, two of six months, eight 
between six and twelve months, three at eighteen months, 
one two years, three four years, and one five years old. 

Symptoms. — It is difficult to say much about the early 
onset of the symptoms. In one or two the complaint has 
come on suddenly after convulsions, or some acute illness ; 
but fifteen out of the above twenty cases had a history of a 
gradual enlargement since the child was two or three months 
old. As to definite symptoms there were generally none. 
Wasting was noticed in four ; two had head pains — one so 
severely that I tapped the skull to relieve the pain, and with 
some success; two had crowing respiration, a symptom 
noticed by Dr. West ; one, giddiness. The increase in size 
is very slow, and often irregular. In eleven cases measure- 
ments were taken from time to time. One had increased J 
in. in three and a half months; another, 1 in. in two months; 



HYDROCEPHALUS. 479 

another, beginning at \j\ in., had gained j in. in a month, 

lost J in. in three months, and then increased to 18 } in three 
and a half months ; another remained stationary. There 
had been no fever in these cases. 

As the disease progresses, and the intra-cranial pressure 
begins to" tell, the child begins to waste ; sometimes it has 
convulsions; ultimately it becomes blind, has nystagmus, 
and so dies gradually exhausted. Once or twice there has 
been some rigidity of the limbs ; once retraction of the head. 
An examination of the eye in the later stages may show a 
swollen or inflamed disc, or a white and atrophied one. The 
latter has been more common in my experience. The cere- 
bral symptoms vary much. The cases I have seen have 
seemed to me to present an average intelligence; sometimes 
an old-fashioned pseudo-precocity, such as Sir W. Jenner 
pictures in rickets, unless the enlargement be extreme. In 
the latter case there has usually been blindness, intelligence 
has failed more or less completely, and the child has lain in 
bed taking notice of nothing. It feeds and sleeps; perhaps 
leading a painless existence ; perhaps exhibiting some signs 
of pain on movement. It is not often that one has the op- 
portunity of tracing cases on from the early stage of the dis- 
ease to its completion. They are met with either early or 
late ; if the former, then the symptoms are of equivocal 
meaning; in the late stage, the wasting, the pain, the blind- 
ness, and the enormous head cannot be mistaken. 

Diagnosis. — The term " water on the brain," both to doctor 
and the public, occupies a very similar position in cerebral 
nosology to consumption of the bowels for abdominal dis- 
eases. • It is the refuge of the destitute, and has often been 
made to apply, not only to acute and chronic brain disease, 
but also to the convulsions of rickets or teething, the onset 
of an exanthem, or one of the many gastro-intestinal de- 
rangements which may be met with in profusion. The first 



480 THE DISEASES OF CHILDREN. 

point in the diagnosis is to eradicate from the mind the 
notion that a bulging fontanelle of necessity indicates excess 
of fluid in the ventricles. It much more often means merely 
a congested brain. Not long ago I saw a child with Mr. 
Irwin Palmer, which had had constant convulsions for four 
days, an unusually bulging anterior fontanelle, a widely open 
posterior fontanelle, a retracted head, and a wearing cry. 
There were many points in favor of some acute meningitis 
with effusion. But another view seemed quite possible; 
dentition was proceeding ; and the parents asserted that food 
brought on a fit ; the diet was accordingly reduced, chloral 
and bromide of potassium given to quiet and thus lessen the 
loaded cerebral circulation, and the treatment was quite suc- 
cessful. I suppose there can be no doubt that there was no 
meningitis and no effusion. We must look suspiciously 
upon all cases of supposed sudden effusion, and first deter- 
mine whether there be not some temporary cause in the 
form of preceding or threatening convulsions for the swell- 
ing of the fontanelle. If the bulging be persistent, and the 
head slowly enlarges, if there be head pains certainly not of 
rachitic origin, then we may begin to think of hydrocepha- 
lus. In making a diagnosis the characteristic features of 
hydrocephalus are a very gradual increase in the size of the 
head, without any pyrexia, and often without any evidences 
of ill-health. There may be a history of bygone meningitis, 
or something which denotes the present existence of some 
cerebral tumor. It is liable to be mistaken for rachitic en- 
largement of the skull, but this cannot be often. The rachitic 
skull is quite different. It wants the enlargement in all direc- 
tions which is seen in the hydrocephalic skull, and thus the 
width and overhanging of the forehead, and the prominent 
and divergent eyeballs. The rachitic skull is long and later- 
ally compressed, the forehead is high and square, and the 
bones may become thickened, soft, and tender. Moreover, 



HYDROCEPHALUS. 48 1 

there is the evidence of rickets elsewhere, and the evidence 
of tender bones in all parts. 

The disease may perhaps be. confounded with hypertrophy 
of the brain, which will be described a little later; but this 
condition is so rare and obscure, both in its symptoms and 
in the morbid changes which produce it, that no definite 
means of distinguishing it can be given. 

Prognosis. — A case of advanced hydrocephalus lives, at 
best, a precarious life; but it is certainly instructive to 
notice how long the less serious cases live. Children thus 
affected attend at hospitals for a year or two — at any rate, 
for several months, and then disappear from view; and it is 
my belief that many of the moderate cases hold their own, 
and, so to speak, get well. The pathology of hydrocephalus 
is a subject of great interest. Space has, unfortunately, pro- 
hibited my entering upon it; but putting aside such cases 
as are due to incurable conditions, such as pressure upon 
the veins by cerebral tumors, there is no reason why, if 
hydrocephalus be due to the shutting off of the ventricles 
from the general sub-arachnoid space, the ventricular cavi- 
ties should not strike a balance in many cases, as is often 
seen in hydrocele, for instance, and the equilibrium of secre- 
tion be restored. Whether this be so or not we cannot tell, 
but this much is certain, that hydrocephalic heads in consider- 
able number are seen in the out-patient room at children's 
hospitals. The general health of these children, as a rule, is 
not bad ; the evidences of cerebral trouble are few or none ; 
the enlargement of the head is very slow, and often stationary ; 
the majority are ultimately lost sight of, and only the few 
extreme cases are known to die. Even these linger on for 
a long time, perhaps fairly intelligent, most probably dull ; 
but in the end intelligence fails, sight fails, and the child 
lives a vegetative existence. Death comes sometimes by 
convulsions; sometimes suddenly; sometimes, and this I 



4§2 THE DISEASES OF CHILDREN. 

think most commonly, by progressive emaciation, deepen- 
ing stupor, failure of the respiratory centres, the accumula- 
tion of mucus in the bronchial tubes and asphyxia ; or else, 
by failure of deglutition, food enters the air-passages, and 
latent broncho-pneumonia develops. 

Treatment, — Unfortunately, one is not often in a position 
to be able to come to any conclusion as to what is the cause 
of the disease. All that is possible, in many cases, is to 
hope for the best, that there may have been some bygone 
local inflammation, the effects of which being tided over, 
the equilibrium of secretion may be restored. 

In all cases, therefore, it seems to me advisable to apply 
systematic support to the exterior of the skull as long as 
possible, and — in the hope, again, that something capable 
of absorption may be present — from time to time some 
mercurial ointment or oleate of mercury (five per cent, sol.) 
may be applied, or some iodide of potassium ointment 
rubbed in. This treatment has been recommended by Golis, 
Trousseau, West, and others ; and, although it will often 
fail, it sometimes seems to do good. It must be carried out 
with care. A child's skin is a very delicate texture, and 
the strapping requires to be frequently changed and the 
surface rested, otherwise ugly sores may be made which 
hinder the treatment very seriously. It is better, therefore, 
to strap for three or four days, and then rest a day or two, 
during which time the surface must be regularly and care- 
fully cleansed and bathed now and again with some spirit 
lotion. Obviously, to carry out the intent of the treatment, 
the head should be strapped continuously for as long as 
possible, and the intervals for rest be as short as is compat- 
ible with the preservation of the skin. Internally, iodide of 
iron may be given, or cod-liver oil. Careful attention to 
feeding must be given if the child is wasting. 

As regards tapping, it is not often successful, but there 



HYDROCEPHALUS. 483 

does not appear to be much risk attaching to it. Therefore, 
in advanced cases, if the skull is not too consolidated to 
allow of it, and the child be wasting and in any pain, it ap- 
pears to be worth the trial. The parents must be prepared 
for the possibility of convulsions after and a possibly fatal 
result, and for no very visible success in the way of relief. 

A fine trocar and canula are used and passed into the 
lateral ventricle in the coronal suture at the outer angle of 
the anterior fontanelle, or at a distance sufficient to well 
clear the longitudinal sinus. The amount to be drawn off 
is usually limited by the amount that flows readily, and 
which is often not much. The bones must be carefully 
supported during the flow of fluid ; and, as soon as the 
tension inside the skull is in-sufficient to expel the fluid, 
the canula should be withdrawn and the head carefully 
strapped. In one case, the fluid withdrawn allowed the 
bones at the sagittal sutures to overlap each other, and the 
head assumed a most peculiar appearance from the lateral 
compression that followed. Pressure was kept up by strap- 
ping, and the fluid never reaccumulated. The child was 
alive and in good health eighteen months afterwards. In a 
second case, in a younger child with more acute symptoms, 
tapping was resorted to for the relief of the tension and the 
pain, only two ounces of fluid would flow but the pain was 
certainly relieved. The child died a fortnight later, but 
death had been expected, as there was in all probability 
some meningitis associated with it. In a third case, tap- 
ping was resorted to, but very little fluid would flow, and 
the operation did neither good nor harm. 

External Hydrocephalus. — This term applies to fluid 
collected outside the brain, either in the arachnoid or some 
sac formed either in, or in connection with, one of the mem- 
branes. The origin of this condition is obscure. Most 
authors speak of it as due to hemorrhage into the arach- 



484 THE DISEASES OF CHILDREN. 

noid, and subsequent changes in the clot. It and pachy- 
meningitis interna, or blood cysts of the dura arachnoid, 
are not easily to be distinguished, and the latter are now 
generally believed to be of inflammatory origin. It is also 
occasionally associated with atrophy of the brain, the 
resulting vacuum being filled by cerebro-spinal or serous 
fluid. 

Of symptoms, this condition can hardly be said to have 
any that are well recognized as belonging to it ; but, being 
a cortical affection, it might be expected to be more associ- 
ated with convulsions and rigidity of the limbs on one side 
or the other. 

The diagnosis of such a case will present great difficul- 
ties. It will depend much upon the irregular shape of the 
head, such as a local bulging in one part or another, or, 
perhaps, a local condition of craniotabes. Perhaps it may 
be well to say that local enlargement of the head is a char- 
acteristic of some tumors, particularly of the posterior seg- 
ment in cerebellar tumors. 

Treatment. — This form often gives more hope of suc- 
cessful treatment. Tapping, and even repeated tapping, has 
already cured such cases ; and it seems reasonable to hope 
that, with all the modern improvements in surgical pro- 
cedure, tapping or other means for removing the fluid 
might be carried out with a fair chance of a permanent 
cure. 



INTRA-CRANIAL TUMORS. 485 



CHAPTER XXXV. 

INTRA-CRANIAL TUMORS. 

Encephalic Tumors. — The brain substance may be occu- 
pied by tumors of many kinds, but the large proportion of 
those which occur in childhood are of a tubercular nature, 
and are situated for some reason or other in the cerebellum, 
or, at any rate, below the level of the tentorium cerebelli. 
That masses of tubercle should be a frequent cause of dis- 
ease of the brain in childhood is only what might be ex- 
pected, when we remember the remarkably lymphoid struc- 
ture of the peri-vascular spaces in the brain, and the 
frequency of tubercular meningitis. It is less easy to say 
why the cerebellum, and perhaps the pons, should be so 
frequently attacked. Several reasons might be suggested, 
but inasmuch as no single one carries any conviction of its 
sufficiency, they need not be stated. The fact remains — 
tubercular tumors are very common in the cerebellum and 
the pons Varolii. The realization of this carries with it an 
aid to the diagnosis of the several varieties of intra-cranial 
tumors. 

Symptoms. — It is well known that tumors of the cerebral 
substance, unless they are of large size or attack particular 
strands of nerve substance, give very indefinite signs of their 
existence. Tumors in the cerebellum or pons give symp- 
toms which very seldom allow room for mistake. These are 
— intense occipital headache and vomiting, congestion, swell- 
ing, and neuritis of the optic nerves, followed by white 
atrophy and blindness, a reeling gait, tonic convulsions or 
rigidity, movements of the eyeballs, enlargement of the occi- 

41 



486 THE DISEASES OF CHILDREN. 

pital segment of the head, and hydrocephalus, or craniotabes. 
Some of these are symptoms we should naturally expect 
from a tumor, at any rate of any size, taking up its position 
in parts closely surrounded by such unyielding structures as 
confine the posterior fossa of the skull. We are familiar with 
the terrible pain of an abscess pent up in fibrous structures, 
and it is more than likely that a tumor in the region in ques- 
tion acts similarly — it deranges the circulation, produces 
congestion, tension, and other abnormal relations in parts of 
a sensitive and vital activity, and the resulting distress is the 
natural outcome. Hydrocephalus is also easily explicable 
from the pressure upon the tentorium which must ensue, 
and the consequent liability to closure of the veins of the 
choroidal plexuses, or of the communications between the 
ventricular cavities and the sub-arachnoid space. The un- 
steadiness of gait is also a well-known feature of cerebellar 
disease ; rigidity, also, and movements of the eyeballs. These 
have all been proved to occur by experiments made by Fer- 
rier with the object of determining the functions of the cere- 
bellum, or those of its parts. Some of these symptoms are 
more constant than others, and of particular importance are 
the unsteady movements in walking and evidences of optic 
neuritis or congestion. These are rarely wanting, and 
optic neuritis particularly may be an early symptom. Rigid- 
ity comes next. Perverted movements of the eyeballs are 
less constant ; and enlargement of the head is often absent, 
and can hardly be expected where the bones of the head are 
ossified. In this case there may be craniotabes. 

Morbid Anatomy. — Solitary tubercle is the commonest 
form of tumor in the cerebellum, and its most favorite seat 
appears to be the hinder part of one or other lateral lobe ; 
occasionally there is a smaller mass in the opposite lobe. 
But other tumors exist sometimes — gliomatous growths and 
either cystic tumors or simple cysts. The latter, although 



INTRACRANIAL TUMORS. 487 

not common, maybe kept well in memory. I must have seen 
some five or six cases, and one can never see a fatal ending 
in such as these without regretting that surgery was not 
allowed a chance to cure. 

Diagnosis. — The symptoms of cerebellar tumor admit, as 
I have said, of little mistake; but it must, of course, be un- 
derstood that tumors in this part are liable to implicate by 
continuity the neighboring parts, and thus produce other 
symptoms. Tumors in the pons Varolii, or growing from 
the tentorium, might compress or spread to the cerebellum, 
and thus produce the symptoms of a tumor of the latter. 

A tumor, if located in the pons, may produce nothing but 
general tremor of the acting muscles. More often there is 
some paresis of the extremities on one or both sides; some- 
times paralysis of the third or sixth nerves, and so on. Glio- 
mata in the pons, moreover, have a tendency to enlarge the 
pons uniformly, so that, on section, the disease looks more 
hypertrophic than of foreign material, but when they reach 
the surface, they may become sub-lobulated and implicate 
the trunks of the neighboring nerves. I have seen three 
such gliomatous enlargements, of one of which a short note 
follows. A boy of 9 years was stated to have been quite 
well one month before his admission. He then began to 
fall about, complained of inability to swallow his food, and 
once or twice almost choked. He was admitted with right 
facial paralysis and paralysis of the right side of the tongue, 
and a staggering gait. His optic discs were normal (this seems 
to be a point in the case which might prove of diagnostic 
importance in similar cases). After a short stay in hospital, 
he gradually lost power in his left arm and then in his left 
leg, and lastly he became rigid on both sides. He died in a 
semi-comatose state. At the post-mortem, the entire pons 
and medulla were swollen by a general hypertrophic enlarge- 
ment, so that it was impossible to say, from the naked-eye 



488 THE DISEASES OF CHILDREN. 

examination, where the disease began or ended. The sur- 
face of the tumor was very peculiar from the number of small 
lobules over it, and which gave it somewhat the appearance 
of the wattles of a fowl. Dr. Angel Money has described two 
similar cases,* and gives a typical representation of one ; Dr. 
Gee and Dr. Percy Kidd have each recorded another, and 
it is probable that others have gone unrecorded rather than 
that they are very rare. Gliomata are slowly growing tumors ; 
they infiltrate the part, so that it is impossible to state precisely 
the boundaries of the growth. Between tnmors of the pons 
and cerebellar tumors it will sometimes be difficult to decide. 
The existence of muscular feebleness, or general paralysis, 
or local paralysis of the nerves, will be in favor of the affec- 
tion being located in the pons ; and it may probably be said 
that, given a lesion limited to each part, the muscular irreg- 
ularity is more of a general tremor when the lesion is in 
the pons — a more irregular and jerky form of ataxia when 
the cerebellum is affected. Rigidity may, it would seem, go 
with either. 

Prognosis. — This resolves itself into a question of how 
long. If we can, by the general aspect of the case, exclude 
a mass of yellow tubercle, then glioma, being the next most 
probable condition, is liable to go on a long time, but the 
ultimate result is no less sure. Tubercular masses also are 
sometimes of very slow growth, and sometimes become 
quiescent for a time, but ultimately they cause death, either 
as tumors, or by the extension from their margins of a tu- 
bercular meningitis. 

Treatment. — With perhaps an exception to be mentioned 
directly in the case of simple cysts, the treatment resolves 
itself into the relief of pain and careful nursing. For the 
relief of pain, iodide and bromide of potassium, chloral 
hydrate, or opium must be given ; and in one case, these 

* " Med.-Chir. Trans.," vol. lxvi. 



INTRA-CRANIAL TUMORS. 489 

means being insufficient and the pain apparently terrible, I 
considered myself justified in resorting to trephining. It was 
in a child of three years, with evident indications of a cere- 
bellar tumor. Mr. Jacobson trephined the skull in the left 
half of the posterior fossa, as low down as possible, so as to 
avoid the lateral sinus ; and in the bare hope that the tumor 
might be cystic, a fine trocar was passed into the cerebellum, 
but without any result. The trephine wound was made as 
large as possible, with the idea of relieving the tension below 
the tentorium, and for a time the screaming fits were some- 
what relieved. The part healed very rapidly, and deep down 
in the neck a firm membranous covering closed in the aper- 
ture, and the relief gained was not for long. The case ulti- 
mately proved to be tubercular. Nevertheless, this treatment 
seems to be worthy of consideration, not only for the relief 
of pain, but in other cases for another reason — viz., the ten- 
dency that exists in the cerebellum for the formation of 
simple cysts. There is no means of arriving at a diagnosis 
without the trephine, and it seems to be quite worth the 
while, in a disease which is hopeless without it, to give the 
patient just the faint chance trephining offers of coming upon 
a cyst and evacuating its contents. Modern antiseptic sur- 
gery has taken away much of the danger that attached in 
former times to trephining, and there is probably no extra- 
ordinary risk in the operation, nor in puncturing the mem- 
branes and lateral lobes of the cerebellum with a fine trocar. 



49° THE DISEASES OF CHILDREN. 



CHAPTER XXXVI. 

HYPERTROPHY OF THE BRAIN.— CEREBRAL HEMORRHAGE.— 
THROMBOSIS OF THE CEREBRAL SINUSES. 

Hypertrophy and Sclerosis of the Brain are usually 
mentioned by all writers on diseases of children, but it may 
be noted that the literature of the subject increases very 
slowly, and that writers allude to their own personal knowl- 
edge of it in a somewhat vague manner. The only recent 
addition to our knowledge appears to be that, whereas, in 
former times the nature of the disease was unknown, of late 
years the condition has been definitely described as due to 
an increase of the neuroglia of the brain — to the disease 
therefore which is now called sclerosis. I see no reason 
why both diffused and disseminated sclerosis should not 
occasionally occur. I have said elsewhere that children 
occasionally come under notice with symptoms very closely 
resembling those of disseminated sclerosis in the adult. But 
the actual demonstration of the condition by post-mortem 
evidence is scanty in the extreme, and I do not know that 
as yet it can be said to have been shown to have occurred. 
In reading over the cases of hypertrophy of the brain re- 
corded, one cannot but be struck with its close association 
with a rachitic skeleton ; and inasmuch as a thick skull is 
found in rickets, one is doubtful in some cases, in the absence 
of actual weights, how far the large head was due to actual 
increase of brain matter, how far to the size of the skull. 
Dr. Gee has recorded two cases,* however, in which the 
brain was very heavy. A boy aged 2^, highly rickety, and 

* " On Convulsions in Children," St. Barth. Hosp. Reports, vol. iii., p. 109. 



HYPERTROPHY OF THE BRAIN, ETC. 49 1 

suffering from convulsions ; the body weighed 17^ lbs., the 
brain 59 oz. ; the average at this age being 38.71 oz. A 
girl of the same age, and also rickety, weighed 15^ lbs., and 
the brain 42^ oz., the average being 34.97 oz. In both 
cases the brain appeared to be perfectly healthy. I should 
myself be disposed, while calling attention to its possible 
existence and to the necessity of closely investigating all 
curious brain symptoms that occur in cases of rickets or 
elsewhere, to emphasize the remark of Dr. West, made long 
ago, but still true, " I am not sure that an undue importance 
has not sometimes been attached to it, as though it were of 
much more common occurrence than you will find it to be 
in practice." I have not hitherto met with such a case. 

Dr. Hillier says of it that it comes on slowly at an early 
age, and is attended with loss of health, dulness, and apathy ; 
the head seems too heavy for the child, and it frequently 
bores in the pillow. 

Cerebral Hemorrhage is a rare disease, but it is never- 
theless an important one. It may be meningeal or intra- 
arachnoid (the two cannot be separated), or into the substance 
of the brain. The former is most probably more common 
than it has been proved to be upon the post-mortem table, 
for the reason that in many cases there can be no obstacle 
to recovery, and looking to the many possible causes of 
such a condition in early life, it is very likely indeed that 
some, if not many, of the chronic thickenings, cysts, and 
other affections of the membranes, which are denominated 
inflammatory, may have their origin in surface hemorrhage. 
It cannot, however, be said that this is certainly so, except 
in a few instances. 

Meningeal Hemorrhage may be of all degrees of 
severity, from mere capillary ecchymosis to a diffused layer 
of clot of some standing. It appears to be more common 
in new-born children, the reason for this no doubt being 



492 THE DISEASES OF CHILDREN. 

the disadvantageous conditions of the circulation which 
occur during delivery, whether natural or instrumental, and 
the circulatory changes that take place within a short time 
of birth. Of other conditions, whooping-cough and severe 
purpura will at once occur to any one as liable to lead to it, 
and cases are on record due to both these diseases. Throm- 
bosis of the sinuses, the various abnormal blood conditions 
met with in the exanthemata and other fevers, are also 
noticed as being occasional causes. 

Symptoms. — It cannot be said to have any which are 
pathognomonic, but in any case in which its existence is 
rendered probable a sudden coma or collapse, a weakness 
of the limbs on one side or the other, perhaps a convulsion 
also, might lead to a guess that something of the kind had 
happened. 

Prognosis. — It might fairly be hoped that by quietude 
and careful feeding absorption of the clot would take place 
and recovery ensue. But for such a case it may be well to 
say that although the prognosis might be very favorable, 
there is abundant evidence in adult life to show that menin- 
geal extravasations are slow in disappearing completely — 
pigment and thin layers of lymph are found, many months 
after extravasation of this kind. Consequently the greatest 
care is necessary to preserve the patient as much as possible 
from excitement or active brain work for a considerable time 
after such an occurrence. 

Hemorrhage into the substance of the brain has in very 
rare cases been due to atheroma of the vessels, but it is 
commonly due to embolism from heart disease, and the 
hemorrhage is commonly preceded by the formation of an 
aneurism. 

Symptoms. — These would be those of apoplexy in the 
adult — viz., sudden onset of right hemiplegia with more or 
less coma, or some general paralysis if the plug should 



HYPERTROPHY OF THE BRAIN, ETC. 493 

block the basilar artery, instead of the more usual seat of 
left or right internal carotid at the base of the brain. 

The diagnosis would mostly depend upon the evidence 
of the existence of heart disease, or of some reason for the 
formation of clots on the valves or in the cavities — either 
from recent rheumatism, or chorea for the valves ; or scar- 
latina, or typhoid, or other exhausting illness for dilatation 
of the left ventricle. It will often be difficult to say 
whether the embolism remains as such, and the paralysis 
is embolic only; or whether an apoplexy has followed it. 

Prognosis is grave in all cases from valvular disease, 
because the embolism most commonly occurs, or at any 
rate produces such severe symptoms, in the worst cases 
only. The valvular disease is likely to be of fungating or 
ulcerative form; the patient to be febrile and anaemic; very 
likely with albuminuria from a dilated ventricle, because 
hemorrhage following upon embolism denotes extensive 
softening, and, in the rare cases due to atheroma, because 
the disease has been usually basilar and the hemorrhage 
into the pons or its neighborhood. Supposing that hemor- 
hage could be excluded and the case diagnosed to be one of 
embolism only, probably a slight distinction might be made 
in favor of clots discharged from a dilated ventricle. I 
think that these, not having an inflammatory origin, are 
less likely to provoke a local inflammation in the vessels in 
which they lodge than are those which are discharged from 
an inflammatory focus on the valve. 

Treatment. — Absolute rest ; ice or cold lotions to the 
head ; the bowels should be kept active, and food adminis- 
tered carefully. Here, too, as in adults, the lungs should 
be watched and preserved from the accumulation of mucus 
at their bases, by attending to the position of the child 
which should be frequently changed from side to side. 

In the more common cases of apoplexy, due to valvular 

42 



494 THE DISEASES OF CHILDREN. 

disease, one- or two-grain doses of quinine should be given 
if there be any pyrexia, and the heart's action should be 
quieted and sustained by bromide of potassium, belladonna, 
or digitalis. 

Thrombosis of the Cerebral Sinuses. — In the larger 
number of cases the lateral sinuses only, one or both, are 
affected. The longitudinal sinus also, but rarely. In these 
cases the lesion is due to disease of bone, and in infancy 
chiefly to disease of the ear, whilst the inflammation of the 
petrous portion of the temporal bone causes phlebitis of the 
petrosal or lateral sinus. But there are also many other 
cases, and the majority children under two years of age, in 
which no such causes can be found. In these it has been 
noticed that the clot is less in the lateral than in the longi- 
tudinal sinus. 

Virchow originally pointed out that not only in the 
cranium but in the pelvic veins and the veins of the lower 
extremity, the blood current is at times so slow as to render 
spontaneous coagulation a risk, and in the longitudinal 
sinus of the cranium the shape of the channel, and the fact 
that the tributary veins run into it in a direction against the 
current, have always been considered as in favor of throm- 
bosis. Thus, when no cause has been found for the coagu- 
lation, as has often happened, it has been assumed that the 
coagula are due to these natural conditions telling disadvan- 
tageously upon an unnaturally feeble current. 

A very good division, therefore, of the cases of thrombosis 
of the cerebral sinuses is that given by Steiner, into exhaus- 
tive and inflammatory. The exhaustive essentially concern 
the longitudinal sinus, and are found in any feeble depressed 
conditions, such as cholera infantum, scrofula, rickets, etc. 
The inflammatory form affects chiefly the basal sinuses, and 
can be traced to disease of the ear, and injuries or local in- 
flammation of the cerebral membranes. 



HYPERTROPHY OF THE BRAIN, ETC. 495 

The symptoms arc very obscure, and the thrombosis is 
found by accident at the autopsy. Lethargy, stupor, or 
coma are the more common — epistaxis, occasionally result- 
ing from plugging of the longitudinal sinus. Any obstruc- 
tion in the cavernous sinus — which, however, is very rare — 
might be detected by the morbid appearance of venous 
congestion visible by the ophthalmoscope at the fundus 
oculi. 

Treatment. — The exhaustive form is one for prevention 
rather than cure. The risk is to be remembered in feeble 
infants, and wine and good food administered. So also is 
the inflammatory form one for prevention, seeing that it 
arises so often from disease of the temporal bone, and that 
this follows upon discharge from the ear. Much may be 
done by paying careful attention to cleanliness and the 
application of antiseptic collyria in cases of this kind, and 
— should any evidence of disease of the bone unfortunately 
arise — timely surgical interference by an incision over the 
mastoid and trephining may possibly give an outlet for foetid 
material and thus avert a fatal result. 



49& THE DISEASES OF CHILDREN. 



CHAPTER XXXVII. 

DISORDERS OF MOVEMENT. 

Infantile Paralysis. — The alpha and omega of the stu- 
dent's knowledge on this subject comprises often no more 
than a few facts about what has from time immemorial 
received the name of infantile paralysis. But there are at 
least several other forms of paralysis which, if not quite so 
disproportionately infantile, are nevertheless common in 
childhood, and deserve to be reckoned among the diseases 
of children. And others, again, though occurring more 
often in adults than in children, which must be enumerated 
as occasional occurrences, lest being unexpected their import 
may be mistaken. I shall not attempt any scientific classi- 
fication of these, because our knowledge of their causes, 
or rather of the lesions by which they are produced, is still 
very meagre. Some are due to cerebral, others to spinal 
lesions ; some, probably, to no lesion at all. I shall take 
them as they most frequently come under the notice of the 
student. 

Infantile Palsy, as the most familiar form of the disease, 
may be taken as a starting-point. " Essential paralysis" it 
is sometimes called, because at one time it was supposed to 
be due to a disease of the muscle. Some still contend that 
a muscular lesion is the primary fault, and that the nerves 
or cord undergo subsequent changes from an ascending 
neuritis. But the generally received doctrine is that the 
paralysis is due to a primary disease of the nerve-cells of the 
anterior cornua of the spinal cord. It is a disease which is 
not confined to infancy, but so largely preponderates then 



DISORDERS OF MOVEMENT. 497 

that 154 cases, out of a total of 205, occurred between the 
ages of six months and two years. It has been noticed 
within a few days after birth. (Ross.) It is liable to affect 
the healthiest children, attacking either sex equally, and is 
said to be more common in the summer months. I have 
sometimes thought that a rheumatic parentage might have 
something to do with its production, but nothing is known 
regarding this. Duchenne states that he has not been able 
to associate it with nervous disease of any kind in the family. 
Of exciting causes, exposure to cold is often mentioned, and 
of this the following is a striking instance : 

A male child of five months old was sent to me by Mr. 
Richardson, of Croydon, with this history. Its father had 
suffered from rheumatic fever badly. The child was taken 
out in October, when six weeks old, and kept out on a cold 
day, for two and a half hours, late in the afternoon. It was 
brought home " perished " with cold, and with its eyes 
drawn up, and snatching its breath. It was in a burning 
heat all night, and kept starting as if falling. It was uncon- 
scious for a week or more, and was continually moaning. 
It gradually recovered from the coma, and at the end of a 
fortnight its right arm was found to be quite useless. This 
had recovered somewhat since, but was still useless in great 
measure. 

Symptoms. — These will be best illustrated by a case. The 
one already given is a typical one, but another may be 
added. 

A boy ten months old went to bed quite well one night, 
and when taken up the next morning was " paralyzed all 
over " — that is to say, his head dropped about, and he had 
no power of sitting or moving — the trunk muscles being 
paralyzed. He was also feverish, but no teeth were being 
cut at that time. The leg was noticed to waste afterwards, 
and use in it was never regained, although the general par- 



49§ THE DISEASES OF CHILDREN. 

alysis improved. The child was brought to the hospital two 
months after the attack. His right leg was mottled from 
cold ; it hung flaccid from the pelvis, and was perfectly- 
powerless. On passive movement, it could be put into 
almost any position, the hip being unnaturally lax, without 
any pain. In all other respects the boy seemed quite healthy. 
Dentition had progressed rapidly, and he was not rickety. 
The muscles failed to respond to the Faradic current, but 
reacted slightly to galvanism. 

Such is the short and usual history of infantile paralysis. 
A healthy child sits in a draught, gets cold, cuts a tooth — 
anything possibly, nothing certainly — and becomes feverish, 
fretful, is perhaps convulsed or semi-comatose, and is shortly 
found to have general .paralysis. The child often cries when 
it is moved about, or when its limbs are touched ; but it is 
doubtful whether this is due to pain or merely to the dis- 
turbance when it is not feeling well. In a day or two the 
fever passes off, and with it, perhaps, some of the paralysis ; 
leaving a leg or an arm, or both legs, or perhaps one side, 
or perhaps only this or that group of muscles, completely 
paralyzed. If the child is taken to the doctor he recognizes 
at once the dangled limb, and finds more or less complete 
absence of response to the Faradic current ; more or less 
qualified action with the galvanic current, but no alteration 
of sensation. This, however, is hardly a common hospital 
experience. Three or four months usually elapse before 
medical aid is sought. By that time the limb is much 
wasted ; the skin is often livid from the sluggish circulation 
consequent upon the reduction of temperature ; all the soft 
parts are flabby, and the electric irritability to any form of 
current is quite destroyed. Perhaps years elapse, and then, 
in addition, there is dwarfing of the affected limb from dimin- 
ished growth, and sometimes deformity from the unbalanced 
action of those groups of muscles which are not paralyzed. 



DISORDERS OF MOVEMENT. 499 

Deformity is, possibly, less common in infantile than in other 
forms of paralysis, excepting perhaps that of talipes equinus 
and varus, because it so frequently happens that the entire 
limb is affected. 

The characteristic features of the disease, then, are : The 
initial fever, the sudden onset of motor paralysis, the rapid 
loss of electric contractility in all those muscles which are 
severely affected, followed by their progressive atrophy, and 
the gradual restoration subsequently of all those muscles in 
which the electric contractility is preserved at the end of the 
first fortnight. There is no progressive character about the 
disease — the mischief appears to be worked at once and then 
ceases. The affected muscles atrophy, but no fresh ones are 
attacked ; and while perfect recovery is perhaps seldom seen, 
a partial recovery is the rule. 

All reflex actions are lost in the affected muscles, to be 
regained, however, as the muscles recover themselves. Sen- 
sation is unaffected. 

As regards the fever at the onset, Duchenne states it to 
be usually, but not invariably, present — of seventy cases it 
was absent in seven. But no negative statement of this kind 
is of great value when such young subjects are concerned. 
Moderate fever is so often unappreciable except to the ther- 
mometer. 

The seat of the paralysis is very variable. The following 
table is from Duchenne's & Electrisation Localise e, as given 
by Dr. Poore. 

In sixty-two cases there were : 

5 of general paralysis. 
9 of paraplegia. 

1 of hemiplegia. 

2 of crossed paralysis. 

25 of paralysis of right leg. 



50C THE DISEASES OF CHILDREN. 

7 of paralysis ofleft leg. 
10 of paralysis of right or left arm. 
2 of lateral paralysis of the upper limb. 
I paralysis of trunk and abdomen. 

In my own cases the right leg was paralyzed in six; the 
left leg and left arm once each ; the right arm twice ; the dis- 
tribution was hemiplegic once, general twice ; in both legs 
three times ; in five out of sixteen cases the pain at onset 
appears to have been pronounced. 

Morbid Anatomy and Pathology. — This form of paralysis 
has been supposed to be due now to muscular disease, now 
to disease of the nerve-endings in the muscles, or to disease 
of the efferent trunks. But all the examinations of recent 
years have gone to show that there is an actual disease, 
inflammation it is called, of the spinal cord. The affected 
muscles, undergo rapid fatty degeneration, but only in con- 
sequence of irreparable destruction of the motor areas in 
the cord. The changes which occur are as follows : In the 
earlier stages small foci of softening are found in the grey 
matter of the anterior cornua. They are usually of small 
size, run in vertical streaks, and are particularly liable to 
attack the cervical and lumbar enlargements. They maybe 
of reddish color, and under the microscope show an increase 
of the capillary network, and cedema of the vessel-walls, with 
a nuclear growth in more or less profusion. In the later 
stages, as might be imagined from what is known of the 
laws of pathological changes, the appearances are those of 
the so-called sclerosis — that is to say, the connective tissue 
between the nerve-fibres undergoes increase and thickening, 
and the nerve-cells and nerve- fibres become atrophied. The 
common appearances in old cases of infantile paralysis are 
diminution in size of the affected part of the cord — diminu- 
tion of the one anterior horn of grey matter as compared 



DISORDERS OF MOVEMENT. 50I 

with the other, and shrivelling and over-pigmentation of the 
nerve-cells. Sometimes the corpora amylacea of nerve de- 
generation are found also. The nerve-trunks related to the 
affected limb are smaller than those on the other side, and 
the muscles are atrophied, and, in many cases, replaced 
almost entirely by fat. 

Finally, it is worth remark that the bones of the affected 
extremities are stunted, and that not in proportion to the 
extent of the paralysis, i. e. } to the want of movement. Very 
slight paralysis may be* attended with much shortening, and 
in extreme paralysis the affected limb may be no shorter 
than its fellow. 

The disease which produces all this mischief in the cord 
is an acute anterior polio-myelitis, or an acute inflammation 
of the motor cells ; and this opinion is based upon all the 
hitherto recorded microscopical examinations of the spinal 
cord. Some have discussed whether the change is in the 
nerve-cells or in the interstitial matter surrounding them, but 
this is a matter upon which we have no evidence, and which 
is not of importance. In one or two cases the appearances 
have been those of a small extravasation of blood in the cord, 
rather than an inflammatory condition. 

But, at the same time, it must also be remembered that 
the cases examined are by no means many, and the majority 
of these have been procured many months, in most many 
years, after the lesion has occurred. Only in one or two has 
the disease been so recent as two months after the onset of 
the paralysis. In saying this I am by no means wishing to 
call in question the facts recorded, but only to impress more 
strongly that we are as yet quite in ignorance of the essen- 
tial cause of the disease. Even allowing the morbid anatomy 
to be as I have stated, we yet require to know what leads 
to the disease in the spinal cord — it is still to clinical data 
that we have to appeal in great measure to support our view 



502 THE DISEASES OF CHILDREN. 

of its nature. Now these data are of two kinds, and seem to 
point in different directions. 

1st. One class of cases is attended with fever, often high, 
and the paralysis is at its first onset a general paralysis, and 
I believe often associated with pain. This class furnishes a 
conclusive proof of a central nervous affection, for a general 
paralysis can hardly be anything else. It is impossible to 
suppose any sudden general affection of the muscles or of 
the peripheral endings of the nerves. It would seem not so 
very improbable that this initial fever might be the essential 
disease, and the nervous affection the result of it. Acute 
febrile conditions are dangerous to the vitality of all tissues, 
but most of all to the nervous system of a rapidly developing 
infant. All acute febrile disturbance in infancy is liable to 
be ushered in by a convulsion, or, what is still more common, 
by the rigid spasm of arms and legs, fingers and toes, which 
goes by the name of tetany. This is a not infrequent his- 
tory of the onset of a case of infantile paralysis, and there is 
no great improbability in the hypothesis that the paralysis 
is due to some acute febrile disturbance. But it may, per- 
haps, be deemed curious that the febrile state should spend 
its force exclusively on the nerve-cells of the anterior cornua, 
and be, indeed, but partially distributed amongst them. To 
such an objection it might in part be replied, that the nervous 
affections of childhood are largely motor disturbances. Chil- 
dren do not complain of pains and aches with anything like 
the frequency that adults do. Convulsions, spasm, chorea, 
etc., replace pain in great measure, and one would therefore 
suppose that, given a cause, acting equally on all parts, those 
used most and most sensitive would most show the results 
of the working of the cause ; and in childhood, therefore, 
the motor-cells would be likely to fail first. But it is un- 
necessary to adopt this line of argument, because a better is 
at hand — viz., that the pyrexia does not act solely on the 



DISORDERS OF MOVEMENT. 503 

anterior cornua, it acts upon the entire cord, often upon the 
brain and coid, and thus we have at the onset coma or a 
general paralysis and some pain. If this be the case, the 
only peculiarity that needs explanation is the partial distribu- 
tion of the disease, as evidenced by the subsequent symp- 
toms and also by the morbid anatomy. But this is quite 
explicable by what we know of the physiology of the cord. 
In the first place, the cause of the affection being a very 
transitorily acting one, much of the original paralysis gen- 
erally clears up, and thus in the end only a small lesion in 
the cord is discoverable. Then the paths of sensory impres- 
sions are not strictly localized, like the motor. How far 
more common it is to find motor paralysis at any time of 
life, than it and anaesthesia combined ; there may be a com- 
plete loss of motion from even diffused changes in the cord, 
and yet no anaesthesia, a fact that can only be explained by 
assuming, what has indeed been proved by experiment, that 
the sensory currents filter through the cord, rather than run ' 
in streams. Minute lesions in such a case would naturally 
be more difficult to detect when we have no immediate op- 
portunity of examining the diseased structures, and are, 
indeed, mostly unable to do so until many months or years 
after the original affection. 

Some hypothesis of this sort takes away the chief difficulty 
in understanding the disease, or, at any rate, a difficulty 
which is a stumbling-block to many — viz., the impossibility 
of giving any satisfactory suggestion why, as it were with- 
out rhyme or reason, a few motor cells should seem to be 
picked out here or there, and the rest of the cord go scot 
free. It is probable that what seems so apparent is never- 
theless not the real state of the case, but that there is a gen- 
eral acute disturbance, inflammation it may be called provi- 
sionally, of the entire cord, which rapidly subsides as its 
cause, pyrexia, subsides, leaving here and there some parts 



504 THE DISEASES OF CHILDREN. 

shattered by the storm. The parts most conspicuously 
affected will naturally be those in which the motor nerve- 
cells largely congregate, for not only is the motor lesion 
concentrated while the sensory is not, but the motor func- 
tion that is destroyed corresponds with an absolute loss of 
nerve-centre, and this entails other secondary consequences 
of trophic and atrophic character, which must add to the 
primary lesion. I have only to add that it is by no means 
uncommon to find some evidences of mental weakness, ap- 
proaching in one direction or another to imbecility, in the 
subjects of infantile paralysis, though, perhaps, they occur 
less often than one might think, if we carefully distinguish 
between the spinal and cerebral paralyses of childhood. This 
group of cases confirms then, I think, from clinical data, the 
opinion derived from pathological observation, that the spinal 
cord is at fault. Before parting with the subject, the student 
may be reminded that, although we call this disease infantile 
paralysis, yet there is an exact counterpart of it in adults, 
called acute atrophic spinal paralysis of the adult, a rare dis- 
ease, but one which is sometimes seen in the form of general 
paralysis of sudden onset and sudden recovery, for the most 
part^ leaving only groups of muscles paralyzed here and 
there. 

2d. There is, however, another group of cases, in which 
the evidence of a primary spinal affection, although such an 
affection is assumed to be existent, does not appear to be by 
any means so conclusive. There is no evidence of any gen- 
eral paralysis, none, perhaps, of pain. All that can be told 
of the case is that a loss of power in this limb or that has 
been noticed quite suddenly. It often happens that we are 
told that the child was left playing on the floor far some 
time and when taken up was found to be affected, or that 
it went to bed well and woke up paralyzed. This is, no 
doubt, the history which is obtained at first in many un- 



DISORDERS OF MOVEMENT. 505 

doubted cases of anterior polio-myelitis, and to that affection 
all these cases are now uniformly ascribed. Nevertheless, 
some of them bear so much resemblance to some cases of 
facial palsy, as seen in adults, that the question of local and 
not central origin may, I think, occasionally be entertained. 
There is no class of nerve cases more uniformly associated 
with a definite onset than Bell's palsy, as it is called — pa- 
ralysis of the portio dura on either side — and its history is 
this : the patient, a little below par, perhaps, is exposed to 
wet or cold ; very frequently it can be stated that, at a de- 
finite time, he sat in a draught, with a stream of cool air 
playing on his cheek. The history is so constantly one 
of this kind, that it seems to be impossible to associate the 
symptoms with any central lesion, hardly possible to believe 
otherwise than that some local change must have been 
wrought in the nerve, as it lies in its somewhat exposed situa- 
tion on the side of the face or crossing the roof of the tym- 
panum. And what are the symptoms ? They are emphati- 
cally sudden onset, rapid loss of Faradic contractility, and 
more or less complete recovery in the space of a few weeks 
or less. And if it be true that such a cause can produce 
such a result in adults, there is no improbability in supposing 
the existence of some similar, affection in children. It is 
curiously seldom that facial paralysis is found in childhood, 
except under other circumstances presently to be mentioned. 
But in this perhaps we may see in part an illustration of the 
rule, that those parts most subject to use or strain are most 
liable to break down ; in part, perhaps, it is explained by 
the relative degree of liability to exposure and injury which 
various parts suffer at differing periods of existence. The 
limbs in children are all movement, uncontrolled movement, 
and exposed in many cases constantly ; as yet the facial 
nerve, though it is no doubt exposed now as it is later on, 
has not become subject to the constant strain involved in 



505 THE DISEASES OF CHILDREN. 

the ever-varying phases of expression. Thus, I think, is 
explained the fact, that children are liable to suffer from 
local paralysis of limb rather than of face ; and it seems pos- 
sible that, even though the nerves involved be mixed ones, 
yet the sensory function, suffering less, might be difficult of 
detection at this age, and the entire trouble thus pass for 
motor. 

The deformities that ensue will depend in great measure 
upon the muscles that are affected ; the leg muscles being 
prone to suffer, and frequently those of the front of the tibia, 
talipes equinus and equino varus are the more common. 

Diagnosis. — Perhaps it may be thought that there are not 
many diseases for which an anterior polio-myelitis is apt to 
be mistaken, and to a careful examiner this is true; but there 
are several disorders of movement in childhood which have 
to be considered and eliminated in making a diagnosis ; and 
first of all may be mentioned paralysis due to pressure and 
nerve-stretching. I have several times been in doubt between 
infantile paralysis and an affection of this kind. A young 
child is left playing, perhaps on the hard floor, with but little 
power of changing its position, and with its nerves unpro- 
tected by the ossified prominences which seem made to 
shield them in later years. There is, at any rate, nothing 
improbable in the assertion that it was left in health and 
taken up paralyzed. In the upper extremity, nerve-stretch- 
ing, taking the place of direct pressure, may readily lead 
to similar results. Supposing there is a doubt about the 
case, the points to be attended to are alterations of sensa- 
tion, incompleteness of paralysis, and little, if any, disturb- 
ance of the normal electric actions. The previous history 
must also be taken into account, although this is liable to 
mislead in any case. 

Other cases come as paralysis, particularly of the arm, 
which turn out to be due either to injury or disease of the 



DISORDERS OF MOVEMENT. 507 

joint. Injury is very common at the shoulder-joint; acute 
disease of the head of the bone and cartilage is common at 
the hip ; and for elbow and knee there is a local periostitis, 
not at all uncommon and generally syphilitic, which may 
lead to immobility of the limb. To remember the possi- 
bility of these is to avoid any error, for all these lesions are 
prominently painful. An examination of the joint generally 
indicates a difference between the two sides, and for the 
syphilitic affection there is generally a considerable amount 
of swelling just above the joint ; and, of course, if we have 
to go farther, and apply electrical tests, the presence of un- 
diminished electrical excitability should settle any occasional 
difficulty there might be. 

Rachitic paralysis is of the same nature. There are few 
things more common than to have infants brought for par- 
alysis of the legs, and to find that they are rickety. Rachitic 
children have very tender bones. They are not only soft, 
but they are actually tender, and such children constantly 
cry when they are handled hurriedly or roughly. But here, 
again, the existence of rickets should be a diagnostic safe- 
guard, and the persistence of pain makes the solution of the 
case easy. 

Infantile paralysis will sometimes need to be distinguished 
from many other paralyses as they occur in children, and 
perhaps chief of these is the paraplegic form — from paralysis 
due to compression of the spinal cord. In this the para- 
plegia is often very incomplete ; it may be associated with 
rigidity, and the reflexes, in place of being abolished, are 
manifestly exaggerated, whilst the muscular atrophy is re- 
placed by mere flabbiness. Some affections of the bladder 
may also help one to a conclusion, although the irregulari- 
ties of infants in this way tend to obscure an otherwise help- 
ful symptom. The spinal column should, however, in all 
cases be carefully examined, as spinal caries and curvature 
may occur in babies of but a few months old. 



508 THE DISEASES OF CHILDREN. 

Hemorrhage into the cord (haemato-myelia) appears some- 
times to occur, and a diagnosis might indeed be exceedingly 
difficult in some cases. It might be expected to be less local- 
ized in its effects, and thus rather to produce the symptoms 
of central softening, with its anaesthesia, its tendency to bed- 
sores, paralysis of sphincters, and exaggerated reflexes, 

Late cases may also be confounded with the atrophic stage 
of pseudo-hypertrophic paralysis, or progressive muscular 
atrophy. The latter, however, is rare. In late cases of 
infantile paralysis the atrophied muscles may be replaced by 
fat, and pseudo-hypertrophic paralysis is followed by ex- 
treme wasting of the muscles. The history must, in these 
cases, be relied upon. The slow progress of the pseudo- 
hypertrophy, the characteristic walk, and slow atrophy with 
long-retained electrical reactions, must serve in most cases 
to distinguish them. 

Before quitting this part of the subject, and as I have 
already alluded to the occasional occurrence in adults of a 
similar affection, and now again to the occasional appear- 
ance of progressive muscular atrophy in children, it seems 
worth while, from a diagnostic point of view, to draw atten- 
tion to the interesting contrast that exists between infancy 
and adult age as regards the diseases of the spinal cord to 
which the two epochs are liable. 

Acute spinal paralysis is common in children, it is most 
rare in adults; chronic spinal paralysis is common in adults, 
and very rare in childhood. Looking a little further into 
the matter we can see that this is just what might be ex- 
pected. Children are subject to sudden and violent febrile 
attacks, and their tissues are constantly in a state of change 
and development. Adults are far less liable to the exciting 
cause, and their tissues have reached such a condition of 
stability that they do not take offence so readily, but when 
they are disturbed they recover more tardily. On the other 



DISORDERS OF MOVEMENT. 



509 



hand, the conditions which lead to chronic spinal paralysis 
and its consequent muscular atrophy are probably quite dif- 
ferent ; they are in great measure degenerative, or entailed 
by various local diseases of bloodvessels, capillary hemor- 
rhages, and so forth, which are not likely to be found in 
young people at the time of life with which we are now deal- 
ing. At the same time we must be prepared occasionally 
to find such a case even in childhood. 

Prognosis. — Infantile paralysis but rarely threatens life, 
although complete recovery is the exception. Ross states 
that if the Faradic contractility of some muscles and nerves 
be diminished at the end of five days, and abolished during 
the course of the second week, these will remain perma- 
nently paralyzed. The loss of power will, at any rate, be in 
proportion to the completeness of the loss of Faradic irrita- 
bility ; but so long as there is any reaction to either current, 
so long some restoration of motor power may be expected. 
After many months have elapsed of complete paralysis, a 
fortiori, after a year or two — as often happens in hospital 
cases — any hope of recovery is out of place. We can then 
only look for such amelioration as accompanies the better 
nutrition of the limb which sedulous attention may still 
procure. 

• Treatment. — The only question that arises is when to 
commence the application of electricity — that is to say, 
what should be done in the very early stages. It is not 
often that the disease comes under notice at this time, but 
if it should, some advocate resorting at once to electrical 
treatment, whilst others urge that any acute disturbance 
should be allowed time to subside, There is no doubt that 
treatment has to be steered between Scylla and Charybdis 
— those on the one side, seeing the dangers of adding to a 
process they suppose to be inflammatory, advocate rest; 
those on the other insist on the early and hopeless degener- 

43 



5IO THE DISEASES OF CHILDREN. 

ation of muscle if electricity be not resorted to. Now, 
assuming the observations to be correct which have been 
made, and that the early stage of infantile paralysis is one 
of vascularity and cell proliferation in the spinal cord, I 
think there can be no question that we should not be too 
ready to worry the cord into action. I can conceive that 
great harm may be done in such a case. But we must also 
remember that the initial process, in all probability, rapidly 
subsides, and much of the original affection clears up, and 
when this happens — in the course of five or six days after 
the onset — we may begin to pay attention to local treatment. 
Till then I should certainly administer such things as con- 
trol the circulation — aconite, ergot, digitalis, and iodide of 
potassium being the chief. I should probably give half a 
grain of iodide of potassium with a drop of tinct. digitalis 
every two or three hours, or if the fever were severe, half a 
drop of tincture of aconite every hour for a few hours at a 
time. The iodide may be replaced by a grain of hyd. c. 
cret. administered night and morning, or a local inunction 
of mercurial ointment may be adopted over that region of 
the cord which corresponds to the paralysis. Cold baths, 
ice compresses to the spine, and so on, would also be advis- 
able, in such cases as they might respectively seem suited 
to. In the later stages two results may be aimed at — get- 
ting some repair in the spinal cord, and keeping the muscles 
in a good state of nutrition. For the first object electricity 
is usually advised, galvanism being applied either to the 
muscles or to the spine. Erb recommends that the poles 
of the battery be attached to large sponges, one of which is 
applied over the supposed seat of disease behind, and one 
on the abdomen in front, and thus a gentle current is trans- 
mitted through the cord. He thinks little of the value of 
the peripheral application, but it is the one more usually 
adopted. There could hardly be any objection to applying 



DISORDERS OF MOVEMENT. 



5" 



both methods. In the application of electricity to young 
children, however, there is a great difficulty. The sensation 
is a strange one, and frightens them ; it must therefore be 
administered with great caution and patience, the weakest 
currents being used at first and for some time, in the hope 
that the stronger may be more gradually applied. But in 
addition, or rather, I should say, before all things, plenty of 
bathing and rubbing to the muscles by the hand is quite as 
useful in its own way, and quite as essential as the applica- 
tion of electricity, and should be practiced frequently and 
patiently. For this the hand should be well oiled and the 
part rubbed and shampooed gently for a quarter of an hour 
twice a day, and when two or three weeks have passed by 
the child should be encouraged to make what use it can of 
the limb. Another important point is keeping the limb 
warm. A notable characteristic of such parts is their 
lividity and coldness. They should be enveloped in the 
warmest wraps and, in very young children, in cotton 
wool. 

In the various muscular failures, the antagonizing mus- 
cles, so far as is possible, should be controlled in some way 
by aiding the weaker muscles by strapping, or bandages, 
or india-rubber. But for details of this treatment the 
reader must be referred to works which specially treat of 
the subject. 

Hemiplegia. — When a child with loss of power in its 
arm or leg is brought for advice, there is a tendency in the 
mind of the beginner to assume that this is due to infantile 
paralysis. But, according to my experience, it is not un- 
likely to prove on examination to be some other form of 
paralysis than an anterior polio-myelitis, for hemiplegia or 
monoplegia of cerebral origin is not uncommon. 

Causes. — Hemiplegia in an adult is mostly due to apo- 
plexy from atheromatous vessels, to embolism, or to syph- 



512 THE DISEASES OF CHILDREN. 

ilitic thrombosis. In childhood; however, we can exclude 
atheroma, and of syphilitic disease very little is known 
except as a cause of meningitis. I will not, however, go 
so far as to say that syphilitic disease of the vessels is not 
often present. More investigation is wanted in this direc- 
tion ; one of my own cases came on after snuffles. From 
notes of eighteen cases of hemiplegia, the common cause 
appears to be infantile convulsions, or some morbid condition 
associated with them. There was a history of an onset of 
this kind in seven cases. Heart disease will account for 
others — first, by embolism, as in adults ; and secondly, from 
the changes succeeding to some of the exanthemata, more 
particularly scarlatina and typhoid fever (one in eighteen). 
Some cases are no doubt rightly attributed to injury (three 
out of the eighteen), and others are due to the growth of 
tubercle. Tubercle may cause even sudden paralysis, but 
it more frequently produces hemiplegic or monoplegic 
tremors, and weakness of muscular force of any kind. 

Tubercular meningitis but seldom causes hemiplegia, it is 
more liable to cause local paralysis, the chief example of 
which in frequency and importance is squint. But, as 
yellow tubercle, the disease forms masses which, slowly and 
insidiously, undermine parts of vital importance which sud- 
denly give way. They more often occur in the cerebellum, 
but by no means always ; sometimes the cortex cerebri is 
attacked ; sometimes a large mass may be situated in the 
centre of the corpus striatum. Therefore, if there be any 
history of previous wasting ; any of discharge from the ear, 
or ill-health of scrofulous type, it will be wise to be on the 
watch for disease of tubercular nature. Three of the 
eighteen cases before referred to are attributed to tubercle in 
the brain. Tumors other than tubercular are also causes of 
paretic conditions, but since these receive separate consider- 
ation there is no need of their further mention here. 



DISORDERS OF MOVEMENT. 5 I 3 

One other cause of hemiplegia, though not a common 
one, still remains — viz., cerebral abscess. Aural discharge, 
with suppuration in the middle ear, may lead to cerebral 
abscess with or without disease of the petrous portion of 
the temporal bone, and abscess may cause hemiplegia (once 
only in the eighteen). It does not usually do so, because 
the white matter allows of its gradual enlargement without 
symptoms till it gets to the surface, which, when it reaches, 
it inflames and causes death by acute meningitis. 

In three out of eighteen cases no cause could be assigned 
for the attack. 

Lastly, there is hemichorea. To remember its existence, 
as I have so often said, is to detect it, and thus to eliminate 
it from hemiplegia in ordinary. But it is quite a common 
thing for a girl or boy to be brought for paralysis of one 
side or one arm. The child, it may be, has an idiotic ex- 
pression, and the restless twitch of a finger, a shoulder, or 
some of the muscles of face or neck, reveal the disease in a 
moment. With the caution that chorea is a condition in 
which definite embolic paralysis sometimes occurs, we may 
refer the reader to the chapter devoted to chorea for any 
further information concerning that disease. 

Functional hemiplegia is not often found in children, but 
I have seen two well-marked cases in boys — of which a few 
details will be given in the section devoted to functional 
affections. 

Morbid Anatomy. — Very little is actually known about 
many of these cases, but the subject is one of particular 
interest, because, apoplexy of the substance of the brain 
being excluded, one frequent cause in adult life of severance 
of the continuity of the motor tracts is absent; whilst an 
adequate cause of extensive cortical lesion is present in the 
fact that so many cases appear to originate in consequence 
of convulsions. One cannot but suppose that infantile con- 



514 THE DISEASES OF CHILDREN. 

vulsions are not unlikely to produce intense cortical conges- 
tion of the brain, and then to lead to meningeal hemorrhage, 
and to produce hemiplegia. If not this, yet they may initiate 
chronic changes in the membranes, which will not only 
thicken them, but will also compress and lead to atrophy of 
the entire half of the brain. Thus, years afterwards, it may 
happen that a unilateral atrophy of the brain is found, or 
perhaps a large cyst full of serum or chocolate-colored fluid 
and cholesterin. When we find such changes, there is 
generally, from the lapse of time, great obscurity about their 
origin; but we know, from recorded cases, that such dis- 
eases as pertussis, which produce sudden and extreme tur- 
gidity of the vessels of the brain, occasionally cause meningeal 
apoplexy and death. It is, then, a reasonable hypothesis, 
that surface hemorrhages of similiar origin sometimes also 
start more chronic evils. Further, although syphilis but 
seldom leads to gummata, there is evidence in favor of its 
power to produce meningitis, and if this is allowed, it would 
follow as at any rate not improbable that pachymeningitis 
would sometimes be found ; and, besides these causes, there 
are all the slow processes, partly hemorrhagic, partly inflam- 
matory, set in action by injuries and by unhealthy inflam- 
mations about the floor of the skull, chiefly about the 
internal ear. 

As regards embolism, one may wonder that it is not more 
common than it appears to be. Heart disease is common 
enough ; but it is to be remembered that whenever apoplexy 
of the substance of the brain is found in young people, a 
careful search is to be made for an aneurism on some branch 
of the cerebral vessels, and for heart disease, which, through 
embolism, is the common cause of the hemorrhage. The 
hemiplegia, which sometimes occurs after the exanthemata, 
is probably embolic, and due either to some endocardial 
inflammation, or possibly to the detachment of clot which 



DISORDERS OF MOVEMENT. 



5*3 



has formed in some pouch of a dilated ventricle, owing to 
the deterioration of the muscular substance resulting from 
the fever. I ought not to omit to add that cerebral 
besides originating, as already mentioned, is a recognized 
sequel of pleuritic effusion, and of chronic disease of the 
lung, associated with dilated bronchial tubes — a sequel due, 
it must be supposed, to the formation of thrombi in the 
pulmonary veins, to their detachment, and thus to embolism 
of the brain. 

Symptoms. — In my own cases the paralysis was right- 
sided in twelve, left-sided in six. I have never noticed any 
association with aphasia, although such a condition is 
described by Gerhardt. Once or twice I have a note that 
the child had spoken less well since the attack. If it be 
the fact that in most cases of right-sided paralysis aphasia 
is not present, it is a point of great interest — though it is 
what might be expected — that in early life the word-memory 
on both sides receives some cultivation, and it is only in 
later life that that on the left side becomes the main one. 
Of the right-sided cases, all were under six. In one or two 
of the cases some rigidity was associated with the hemi- 
plegia, and this is not an uncommon occurrence; it is men- 
tioned by Gerhardt and other writers. In some cases the 
face is temporarily paralyzed, as in adults : in five this was 
so; in three questionably so ; in eight not; in one there 
was ptosis also, the child dying with a yellow tubercle in its 
brain ; once there was paralysis of the tongue. 

Prognosis. — Many of these cases are not complete, and 
either slowly recover or result in some curious anomalies 
of muscular movement, which may, perhaps, be grouped 
together under one term, athetosis, or post-hemiplegic 
chorea. 

But in some cases the loss of power is complete and per- 
manent ; late rigidity and wasting of the affected extremities 



5 l6 THE DISEASES OF CHILDREN. 

occur, as in adults ; and the development of the entire half 
of the body may be more or less arrested. 

Treatment. — As in other forms of paralysis, when there 
is no reason to suppose that life is in danger from tubercle or 
other causes, every attempt must be made to keep up the 
nutrition of the muscles by massage, bathing, warm cloth- 
ing, etc. Electricity should also be regularly applied to the 
muscles when possible. 

In the earlier cases, for many there is not much to be 
done, save to keep the child quiet, and see that it is fed 
properly and kept clean. Supposing that there is any rea- 
son for suspecting a syphilitic influence, this must of course 
be treated. The ear should also be examined, in case some 
disease may have originated there and an abscess be existing 
inside the skull which might probably be reached by a 
trephining operation. 



MOTOR DISORDERS. 



5 i7 



CHAPTER XXXVIII. 



MOTOR DISORDERS— (Cbnthtued), 



Pseudo-hypertrophic Paralysis is a disease which attacks 
children almost exclusively, and appears to run in families, 
affecting several members of the same stock. Those affected 
are nearly all boys (190 out of 220, Gowers), and as with 
haemophilia, it descends to the males by the females. Many 
of them stammer, and are of feeble intellect, and Chwostek 
has described an enlargement of the tongue in some cases. 
The essential features are enormous buttocks and calves, 
associated with great muscular feebleness, so that the gait is 
peculiar. The other muscles of the body are usually feeble, 
or even wasted, but they seldom show enlargement compa- 
rable to that of the calf and buttock. The disease is of such 
slow progress that few seem to have been able to watch its 
onset, and, lasting as it does for years, not many cases of 
death are recorded. It appears, however, to lead slowly to 
a fatal issue, either by general muscular atrophy and diffi- 
culty of respiration, or general marasmus. 

Morbid Anatomy. — In all cases where an examination 
has been made, the affected muscles have been found to be 
— if in an early stage — separated by abnormal growths of 
fat in the interstitial tissues ; if the stage be late they are 
replaced, or rather crowded out, by fat. The evidence as 
regards the state of the spinal cord is contradictory. The 
examinations of the cord in such cases have not been many, 
and it has once or twice been found diseased ; but the gen- 
eral opinion at present held seems to be that the affection is 
a local one of muscular origin. 

44 



5 l8 THE DISEASES OF CHILDREN. 

The distinctive features of the disease are the slow prog- 
ress and the very gradual loss of electrical power — a loss 
corresponding to but following the wasting ; differing thus 
from that of infantile paralysis, or anterior polio-myelitis, 
which precedes and is out of proportion to the wasting. But 
a time may come in this disease when the muscles being in 
a state of complete atrophy, it is impossible to recognize its 
characteristics, and in which it is difficult to distinguish be- 
tween it and progressive muscular atrophy. 

To my mind this is an important point in the disease. 
The elephantine buttocks and calves and the feeble intellect 
form a clinical picture which perhaps no one could well mis- 
take ; but when we say that the pseudo- hypertrophy may be 
little, the muscular atrophy very general, and that in any 
case of muscular atrophy a growth of fat may appear and 
replace the muscles, the distinction is by no means always 
easy. My own experience has been singularly meagre in 
typical cases, but it has supplied me with several of the more 
doubtful kind, and, inasmuch as they certainly form an in- 
structive group, short notes of them are appended. 

Ernest M., set. 12. His father is a very drowsy man, and 
suffers from intense headache. His mother has had rheu- 
matism twice, and three years ago some nervous affection, 
for which she consulted Dr. YVilks. One of her children 
died of " water on the brain," and another of " cleft palate." 

This boy, when he first began to walk, at fifteen months, 
was noticed to do so in a strange way, walking from his 
hips, swaying from side to side, and not bending his knees. 
When four or five, he improved slightly, and could walk for 
short distances without the aid of sticks. This continued 
till he was about nine, he being able to walk and play in a 
manner, but never like, or with, other boys. At nine years 
old his powers of locomotion again deteriorated ; he refused 
to go out, and when walking would help himself by means 



MOTOR DISORDERS. 



5*9 



of chairs, etc. For the last twelve months he has been car- 
ried about. It was also noticed that while he was becoming 
thin and emaciated, his calves and gluteal regions were well 
developed, in walking about he protruded his buttocks and 
his back was arched. His parents think that for four or five 
years his arms have become thin and wasted. His mental 
condition has always been good. He is a pale boy, with 
stammering speech, but sharp and intelligent. He lies in 
bed, and experiences the greatest difficulty in turning over. 
After much effort, he can manage to raise himself on his 
knees ; but he has to support himself with his arms. His 
legs are spare, and there is talipes equinus of both feet. His 
calf muscles are not large, but they are remarkably hard ; 
and when he lies in bed there is an unusual gap betw r een the 
thighs, which makes it appear that there must be something 
wrong in the setting of his hips ; but this is probably due to 
wasting of his adductor muscles. 

His lower limbs are capable of every variety of movement, 
but in a very feeble way. He takes his hands to help his 
legs when he wishes to cross one over the other. Tendon 
reflexes are all absent. Skin reflexes are all present. When 
he is placed on his feet his buttocks protrude and his spine 
becomes much arched, but probably only because in this 
way alone can he compensate for the talipes, and put his 
feet flat to the ground. 

With electricity, all the muscles, legs, and arms, and 
trunk, fail to respond to a weak Faradic current, to a 
strong one the left arm and leg act more than the right, and 
the trunk muscles act rather better. To a galvanic current 
applied to the muscles there is some response to fifteen cells. 
Electrical sensation is much diminished below the knees. 
Ordinary sensation is undiminished. 

This case was seen by several physicians and surgeons, 
and various views were entertained of its nature, but I ulti- 



520 THE DISEASES OF CHILDREN. 

mately came round to the opinion originally entertained, I 
believe, by Dr. Moxon, that the case was one of the atrophic 
forms of psuedo-hypertrophic paralysis. 

Case 2. — A boy of nine, whom I only saw once as an 
out-patient. He had not been known to be ill, but when he 
ought to have walked it was found that he could not do so. 
He did not walk till he was six years old, and then but 
badly. He was better than he had been. 

He walked in a most decrepit manner, with his knees 
bent and the feet dragging. There was no incoordination 
or jerking. When lying down the limbs were still flexed at 
the knees, and the muscles of the hams were spasmodically 
taut. The limbs were spare without decided wasting, and 
without disease of the joints. He had been treated with 
electricity and cod-liver oil without decided benefit. 

This case seemed in some respects very like that already 
detailed, though its nature must be considered very doubtful. 

Case 3. — A boy of three and a half years. Had good 
health until five months before his admission. He was then 
languid and ill, and if he attempted to walk would fall down. 
He retched in the morning for a week or two. When seen 
by Dr. Willcocks, five or six weeks after this onset, he could 
walk in a tottering manner, with his legs much apart, but if 
laid on his back he could not get up again. About this 
time internal strabismus appeared. Now he can roll over, 
but cannot walk at all. The superficial reflexes are normal ; 
the deep are absent, save slight clonus at the right ankle. 
His limbs are plump, and there is moderate hypertrophy of 
the calf and gluteal muscles. The lumbar muscles stand 
out considerably when he sits up in bed, which he can do 
with a forward lean. He is unable to stand alone, falling 
forward if unsupported. In walking with support he throws 
his legs helplessly about, and keeps them wide apart. In 
attempting to raise himself from the ground he rolls over, 



MOTOR DISORDERS. 



521 



and rests his arms on his knees, but without effect so far as 
getting up is concerned. There is no lordosis. The elec- 
trical reactions are normal with both currents. 

Case 4. — A boy of nine. Began to walk at the age of 
twenty months, but he had always been weak and never able 
to get about like other children. He had gradually im- 
proved without any treatment, and was stated to walk much 
better than he could two years ago. He could walk about 
the ward quite well, but, like Case 5, he had great difficulty 
in mounting the stairs. He could only accomplish this by 
hanging on to the balustrades, and pulling himself up with 
his hands. Further, he could not rise from a sitting pos- 
ture. He would get on his hands and knees and blunder 
about, and, when he would seem almost to have accom- 
plished his purpose, would roll over again. He was a spare 
boy, of average intelligence, and without anything that could 
be called hypertrophy of the muscles, but to very careful 
examination the muscles of his thigh, and particularly the 
extensor cruris, had a hardened feeling which was suspi- 
cious. His thigh muscles failed to act to Faradism in any 
way, but they acted to tw r enty-four cells of a constant cur- 
rent. There was no patellar reflex on either side. He was 
galvanized and shampooed with much regularity for four and 
a half months, but very little improvement resulted. 

Case 5 was a boy of six or seven years, much like the 
last-mentioned case, who was brought to me because he 
could not walk upstairs, or pick himself up from a sitting 
posture. If sitting on the floor, he would turn over on to 
his hands and knees, but the weakness of his glutei and the 
extensors of his legs and thighs was such that he could not 
get himself into the erect posture without assistance. When 
he was erect he had no trouble in walking or running about, 
though I believe he was apt to tumble occasionally. He 
was a very spare boy, but the muscles were not definitely 
wasted, and I supposed his case to be one of this group. 



522 THE DISEASES OF CHILDREN. 

The disorders of movement of patients affected with pseudo- 
hypertrophic paralysis are chiefly dependent upon weakness 
of the muscles of the lower extremities. Feebleness of gait 
is first noticed, and frequent falling; the legs are kept wide 
apart for the sake of steadying the badly-balanced trunk ; as 
they walk there is a half-rotatory, half-shuffling, movement 
to enable the forward step to be taken. Next there is the 
difficulty of getting up from a recumbent posture, the move- 
ment being accomplished by the hands, which, placed upon 
the knees and thighs, push the trunk upwards to supply the 
action of the paralyzed extensors. As the result of the 
paralysis of the extensors of the pelvis on the thighs lordosis 
follows, and later there is talipes equinus, and the patient 
cannot get his heels to the ground. The calf muscles are 
usually the first affected, then follow the glutei, and ulti- 
mately other muscles of the thigh, pelvis, trunk, and upper 
extremities. The pseudo-hypertrophy is a very variable 
element, but in most cases a great deal of quiet atrophy may 
be going on in various parts, obscured by the seeming attrac- 
tion of the parts which are enlarged.* 

Diagnosis. — It needs chiefly to be distinguished from 
infantile paralysis and progressive muscular atrophy. As a 
general rule the history will allow of its distinction from 
infantile paralysis, which comes on suddenly. The latter is 
rare. 

Prognosis. — It does not appear to have any tendency to 
ameliorate. Its course is very chronic, and may last from 

* There is at the present time a boy, aged eight, under my care in the 
Evelina Hospital, who very well illustrates this point ; for, while his calves 
are decidedly prominent, the muscles of his arms and shoulders are v 
This case also emphasizes a point I have observed in others, that it is at 
as important to pay attention to the indication as to the enlargement of the 
muscles. There are muscles of the arm which would pass for normal, or 
possibly as wasted, but which, from their peculiar hardness, are no doubt 
undergoing the changes which in the calves have produced the enlargement. 



MOTOR DISORDERS. 



523 



childhood to puberty. Death usually comes at last from 
exhaustion. 

Progressive Muscular Atrophy is not a disease of child- 
hood, but it occurs occasionally. The following notes are 
perhaps from a case of this kind : 

A boy of nine came for wasting of his right hand. It 
began three years before he came, and went on progress- 
ively for two and a half years, but had been stationary for 
six months. The hand ached much at first when he at- 
tempted to write; and latterly he had had pain and weak- 
ness in the outer side of the arm. He had never had any fit. 

He appeared healthy ; but there was extreme wasting of 
the muscles of the right hand and of the forearm. The fore- 
arm near the elbow measured f inch less than its fellow. 

There are many other curious forms of paralysis met with 
in childhood. I cannot say that they are common, but they 
are met with occasionally. In looking over my notes, and 
attempting to arrange the cases in some order, it seemed to 
me that they would be most instructive if they were simply 
enumerated with such notes of the cases as might seem 
desirable. 

A large group of cases, for example, may fall under the 
denomination of ataxia, using that term in a wide sense to 
indicate imperfect muscular control. In some cases it takes 
the form of rhythmical or irregular movement of the head. 
In infants this is often associated with nystagmus, and then 
is denominated the nodding spasm. Very little is known 
about this affection. There is no suspicion of blindness with 
nystagmus in this association ; and we can only say that it 
appears to be some anomalous play of nerve force ; that it 
is a disorder of dentition more particularly ; and as such is 
liable to come and go with the occasion. Sometimes, how- 
ever, the movements are by no means regular, but are re- 
placed by a decided jerking action, much more at some times 



524 . THE DISEASES OF CHILDREN. 

than others. It is not only confined to infants ; I have seen 
on two or three occasions, in older children, a peculiar jac- 
titating movement of the body, trunk, and extremities, which 
has closely simulated the movements of insular sclerosis in 
the adult. I suspect that cases of this kind have passed for 
such in the few recorded cases of insular sclerosis in child- 
hood ; I do not think that any autopsy has yet confirmed 
the diagnosis. These cases may be found at any age. I 
have notes of such at three and a half, six, and nine years. 
In one case (set. nine) the disease was said to have existed 
from birth. In another case it was apparently hereditary, 
for the father was so unsteady in his fingers that he could 
never button his shirt-collar; whilst his son, a boy of six, 
wrote his name in a series of unintelligible zigzags, and in 
attempting to steady himself to put a glass of water to his 
mouth, the muscular movements became violent. This affec- 
tion had been noticed ever since he first began to play with 
blocks ; but he had never had any fits or any illness. He 
was a sharp, nervous child, and easily frightened by sudden 
noises, and then lost his self-control and stammered. 

In another case a child of six had had a fit, and was 
idiotic, though sensible enough to express his satisfaction 
that he had " done with the doctors " after we had finished 
examining him. He used his hands in an ataxic way ; got 
at a button of his waistcoat with difficulty; and only after 
many efforts, in which the arms made wide excursions, did 
he succeed in unbuttoning. This child spoke slowly and 
laboriously, and walked in a tottering way, and would fall 
quickly if not held up. 

All these were boys. In a girl of four the disease came 
on after " brain fever; " probably the initial fever of measles 
and whooping-cough which she had at that time. 

It is very difficult indeed to refer these cases to any actual 
lesion ; and some would get over the difficulty by calling 



MOTOR DISORDERS. 525 

them congenital chorea. So far as treatment is concerned, 

it is useful to consider them — like the cases of some of the 
imbeciles with spastic paralysis — as instances of faulty con- 
trol and training, which will be bettered by a laborious and 
patient practice. The same thing happens under other cir- 
cumstances. After diphtheria, for example, and in many a 
case of tumor of the pons, the movements are very similar, 
and here there appear to be exactly the conditions required 
for the necessities of the hypothesis that cerebral control 
being stopped, or rather impeded, tremor and jactitation 
result. 

This, indeed, is often the question for diagnosis. A child, 
with tottering gait and jactitating arms, comes for treatment. 
The first thing that occurs to one is the possible existence 
of tumor of the pons or cerebellum. As a mere question of 
muscular disorder, such a case might readily pass for one of 
tumor. The decision must rest upon the existence or not 
of other evidences of tumor, such as optic neuritis, headache, 
vomiting, and the like. 

Facial Paralysis, of any persistence and completeness, 
is, in adults, far more commonly due to peripheral causes, 
such as exposure, than to any known central lesion. In 
children, the reverse happens, and it is but seldom due to 
the like cause. I have seen it once only in a girl of about 
eight years. Henoch and Steiner have, however, recorded 
cases of this kind. It occurs sometimes in infants soon 
after birth, and is due to injury in delivery. It usually 
passes off within a short time ; but the affection sometimes 
remains throughout life. A congenital and irremediable 
form is described by Henoch, the cause of which is un- 
known. 

Abscesses and enlarged glands behind the angle of the 
jaw also produce facial paralysis ; and it has been known to 
result from congenital syphilis (Barlow) ; but, more usually, 



526 THE DISEASES OF CHILDREN. 

it connotes aural discharge and disease of the middle ear. 
Such cases are prone to die from tuberculosis. Disease of 
the ear may cause abscess of the brain and suppurative 
meningitis, as in later life ; but my own experience quite 
coincides with that of others, that tuberculosis, in one part 
or another, is liable to supervene when aural discharge and 
facial paralysis are co-existent. There is usually extensive 
disease of the temporal bone in such cases, and perhaps it 
is thus that it is an evidence of the tubercular tendency. 

Facial paralysis is, therefore, of very sinister omen in 
infants and young children. 

Hemiatrophia Facialis is a very rare condition, but some 
forty or fifty cases have been recorded. Latterly, two very 
striking cases, with photographs, have been published by 
Messrs, Jessop and Brown, from Dr. Gee's wards, in the 
" St Bartholomew's Hospital Reports." The disease is not 
jsively infantile; but Gerhardt has collected ten or 
twelve cases in children, and Jessop states that thirty-five 
began before the age of twent 

It is characterized by wasting of the muscles of one- 
half of the face, generally the left. The palpebral fissure 
narrows, the eye sinks in. the cornea becomes ulcerated, 
and the eye destroyed. In many of the cases there is 
neuralgic pain and some early pigmentation of the skin. 

Three other spasmodic affections may be mentioned in 
one group — viz., internal strabismus, nystagmus and retrac- 
tion of the neck. 

Internal strabismus is the common form of squint. It 
may be either concomitant or paralytic ; the former is due 
to excessive development or excessive use of the internal, 
the latter to paralysis of the external, recti. Concomitant 
squint is much the more common and is mostly due to 
hypermetropia. My colleague, Dr. Braiiey, tells me that 
some error in refraction is present in at least 70 per cent, of 



MOTOR DISORDERS. 

all cases, although in, perhaps, a third of this number the 
hypermetropia is so low that it would be difficult to accept 
it as the real cause of the squint. But by this prevalence 
of hypermetropia sufficient to produce it, a difficult 
introduced because the squint is frequently stated to have 
followed upon a convulsion. A history of this kind must 
be received with great caution, nevertheless it is probably 
true for som- ind one can then only suppose that the 

central disturbance has upset a muscular balance, hitherto 
only maintained with difficulty, and which, once disturbed, 
is unable to recover itself. For such cases as are not due 
to hypermetropia, some are thought to be dependent upon 
some congenital want of balance in the ocular muscles; 
others upon some defect in vision ; others, perhaps, upon 
defect in the centres for the movements of the eyeballs 
either of congenital origin or arising out of the disturbance 
of acute meningitis and so forth. Paralytic squint is most 
often a symptom of tubercular meningitis ; occasionally, 
perhaps, one of the results of a by-gone basal meningitis. 
The treatment of squint belongs to ophthalmic sur:; 

Nystagmus (oscillation of the eyeballs), when not a 
symptom of the nodding spasm,* is usually associated with 
amaurosis, or defective sight. Of six cases, four were blind ; 
it is usually met with in infants a few weeks or months old, 
and is liable to be associated with blindness of any form. 
Thus it is found with cataract, as well as with congenital 
defects at the fundus oculi. The nature of this muscular 
anomaly is obscure, but the fact that many cases occur 
when blindness has prevented the acquirement of the power 
of fixation seems to suggest that the faulty movement, if 
sometimes due to a central lesion, may at others be the re- 
sult of the want of training which the ocular muscles suffer 



--'■-■: 



528 THE DISEASES .OF CHILDREN. 

when faulty vision is congenital or dates from very early 
infancy. The lens and the fundus oculi should be carefully 
examined for local disease. The presence either of cataract 
or possibly some local distribution of retinitis or choroiditis 
might allow us to hold out some hopes of relief by opera- 
tion ; for probably it can be said of this as of other muscular 
aberrations, that, no matter what the primary disease may 
be," some improvement may be expected by allowing educa- 
tion of the muscles to come into play. 

Cervical Opisthotonos is a symptom only, but it is of 
such importance as to demand a paragraph to itself. Dr. 
Gee and Dr. T. Barlow, in the St. Bartholomew's Hospital 
Reports, give notes of twenty-five cases of this affection in 
infants, varying from birth up to nineteen months. It is 
sometimes of gradual, sometimes of sudden, onset. It is 
often chronic, tends to remit in severity, is associated with 
rigidity of the limbs, convulsions, and hydrocephalus, and, 
in the majority of cases, terminates fatally. In all the cases 
(six) in which an examination was made after death, a basal 
meningitis of a non-tubercular nature was found. 

These authors note recoveries in a somewhat cautious 
manner, from the known tendency to remission which the 
disease exhibits ; but there can be no doubt that retraction 
of the neck does subside in some cases, and that even a 
meningitis of the base with retraction occasionally gets well. 

The case must be gone into completely, as sometimes the 
opisthotonos has appeared to me to be like torticollis, either 
of rheumatic origin or due to some temporary gastric dis- 
turbance. 

All these three affections — strabismus, nystagmus, and 
cervical opisthotonos — are worthy of investigation, from the 
interest which attaches to them with respect to the observa- 
tions of recent years as regards the localization of cerebral 
functions. Ferrier has shown that retraction of the head is 



MOTOR DISORDERS. 



529 



associated with destruction of the posterior part of the middle 
lobe of the cerebellum, and that disturbed movements of the 
eyeballs are found with other cerebellar lesions. It seems, 
therefore, not at all unlikely that what has been shown to 
be true for retraction of the head, both experimentally and 
clinically, may also be sometimes true for nystagmus and 
some forms of squint, and that a case may occasionally find 
its explanation in some bygone basal meningitis. 

Torticollis, or stiff neck, might perhaps be made the text 
for dwelling upon the question of the existence of muscular 
spasm from local causes. But, of late years, this latter group 
of cases has been by common consent much reduced by en- 
larging the area of central or nerve spasm. Wry neck, 
however, does seem still to remain more local or functional 
than general. Although in ignorance of its cause, perhaps 
it may be introduced here as related, I think, to occasional 
cases of retracted neck. 

Torticollis is a frequent affection of childhood ; it occurs 
in rheumatic families, in children who are anaemic and out 
of sorts ; it may also occur as a result of reflex irritation 
from enlarged glands, decayed teeth, etc. 

It is a disease of childhood, not of infancy, and cannot, 
therefore, be easily confounded with the spasm and contrac- 
tion due to the sterno-mastoid tumor, sometimes found 
within a short time of birth, and supposed by many to be 
the result of injury to the neck in delivery. 

Treatment. — Any local cause must be looked for, and, if 
possible, remedied. If none can be found it is advisable to 
give some gentle laxative and saline, such as the effervescing 
citrate of magnesium, pyretic saline, or some such mild 
aperient, one drachm three or four times a day, and, after a 
day or two to give Easton syrup or Parrish's food or a like 
tonic. 

Spastic Paralysis is, no doubt, best known in adults as 



530 THE DISEASES OF CHILDREN. 

spastic paraplegia, or spasmodic spinal paralysis, and its 
symptoms are tolerably constant. They are gradually devel- 
oping motor paraplegia, associated with muscular twitch- 
ings and rigidity, sometimes contractures, and a great in- 
crease of the reflex activity of the tendons. The paralysis 
appears to be in great measure due to the excessive reflex 
excitability and the muscular rigidity which exist, and which 
lead to the characteristic gait ; the rigid limbs being dragged 
along with difficulty and the toes clearing the ground badly. 
Certain negative symptoms are not less important as regards 
the diagnosis. There is no affection of sensibility, no wasting 
of the muscles, and no disturbance of the functions of the 
bladder. But §pasm is by no means uncommon in the pa- 
ralysis of children. It is said more often to take on a one- 
sided pattern, and has received the name of spastic hemi- 
plegia ; but whether hemiplegic or paraplegic chiefly, certain 
peculiarities attach to it. First of these is the frequency 
with which it goes with idiocy and also with fits. Of ten 
cases, six boys and four girls, of which I have notes, eight 
were imbecile ; two only are noted to be intelligent. It 
sometimes occurs in the youngest infants with small brains 
(microcephalus) ; but more often it happens that the child 
has been quite well up to a certain time, and has suddenly 
been taken with severe brain symptoms and fits. The in- 
ability to walk has closely followed, and the idiocy has 
slowly supervened. These points are perhaps better illus- 
trated by short notes of cases : 

Case i. — A boy of two and a half has squinted since 
birth, has never been intelligent, and never walked ; has 
never had a fit of any kind ; he is quite imbecile ; there is 
internal strabismus and nystagmus ; the optic discs are 
bluish-white and atrophied; both legs move badly; they 
are spasmodically flexed at the knees, and can only be kept 
straight with difficulty. He is quite unable to stand for this 
reason. 



MOTOR DISORDERS. 

Case 2. — A boy of seven had a fit at the age of three 

years, remained well for twelve months, and gradually after 
this lost power of walking and talking; at first he walked 
on his toes. When lying down, his legs are rigidly extended, 
with pointed toes, resisting attempts at flexion. 

Case 3. — A girl, aged four. The original notes are 1 
She is imbecile ; has fits ; there is internal strabismus, and 
the fundus oculi is hazy and swollen ; her legs and arms 
become quite rigid on slight stimulation ; the legs are so 
rigid that she is quite unable to stand alone. 

Case 4. — A boy of six and three-quarters. His paternal 
aunt became idiotic after fits ; a great-aunt died in an asylum 
with brain disease ; three other children died with convul- 
sions. The present patient was suddenly taken with vomit- 
ing while in bed five weeks before. A fit followed quickly, 
in which he had deviation of head and eyes to left, and loss 
of power in the right leg. He had many fits afterwards, ex- 
tending over a fortnight, and since then has lost his memory 
and power of speech. He does not now recognize his rela- 
tions. He is idiotic, but does as he is told. The right arm 
is rigid, jerking in its movement, and tremulous when ex- 
tended. The leg is in a similar state, although he manages 
to walk in a clumsy and unsteady manner. Sensation is 
normal. He is said to have been quite blind when he had 
the fits, and quite without sensation on the right side, even 
to the pricking of a pin. The fundus oculi is normal. 
Bridge of nose rather sunken, but no evidence of congenital 
syphilis. 

Case 5. — Girl, eight and a half years. Quite well and 
intelligent a year ago. Had a bad feverish attack, and was 
in bed a fortnight. When up again, was unable to use her 
legs well, but crawled about with a chair for six months, and 
now cannot walk at all. Has been getting babyish and 
mischievous for some months ; is now more like a child of 



532 THE DISEASES OF CHILDREN. 

four in her manner. Both legs very wasted; slight contrac- 
tion of the flexors of the knee, so that she is unable to 
straighten them or put the sole to the ground. Pupils equal 
but sluggish ; hearing good, no otorrhcea ; teeth peggy, and 
crammed into the jaw very irregularly. 

Case 6. — Boy, aged three and a half. Early history want- 
ing. He cannot talk, and if he tries to walk, all his muscles 
become stiff. His hands and arms are spasmodically con- 
tracted, the wrists being strongly flexed, and the fingers 
over-extended, so as to be bent backwards towards the dor- 
sum. Muscles flabby, but not wasted. Expression imbecile. 
No note of fits. 

Case 7. — Boy, four and a half. Never had any illness, 
but never able to sit or walk ; head large ; high arched 
palate ; moves his legs irregularly, with much rigidity of 
muscles when attempting to walk, and temporary talipes 
equinus when put on feet. When lying on his back the 
legs and thighs become rigidly flexed ; arms, when attempt- 
ing to grasp, are shot out in a rigid extended manner ; but 
there is some control of left arm ; constant tremor of right 
arm, and athetosis of fingers. 

Case 8. — Girl, aged five. Convulsions a week after birth ; 
has never crawled or walked, and talks badly. Intelligent ; 
sight and hearing good ; picks up things clumsily — the 
ulnar side of hand and fingers being extended in a spas- 
modic manner — right side most marked ; in walking there 
is much initial rigidity of the muscles, which subsequently 
subsides. Some talipes equinus at first ; right leg more 
flabby and smaller than left ; both legs become rigid irregu- 
larly, apparently from irregular muscular action, partly 
reflex and partly voluntary; knee reflex absent on both 
sides. 

Case 9. — A girl, aged two years. Early history wanting. 
The parents are healthy ; but one other child has had "fits." 



MOTOR DISORDERS. 533 

This child has a markedly contracted narrow forehead, with 
a microcephalic appearance and manner. The fontanelle is 
closed: there are no protuberances on the skull, and no 
evidence of rickets ; the face is well developed ; the arms 
and forearms are flexed and rigid; the thumbs inturned 
upon the palms, and the fingers clasped; the legs also are 
rigidly flexed. Directly she is touched the whole body 
passes into a state of rigid spasm, lasting for a few seconds. 

The sight is deficient in certain directions, and there are 
large patches of choroidal atrophy with central pigmenta- 
tion. Both of the discs are white, with pigmented borders, 
and on the right side one of the atrophic patches occupies 
the place of the yellow spot. 

In a tenth case, a boy aged three years, the distribution 
is paraplegic, and there is internal strabismus, with a skull 
of microcephalic type. But the child is rather precocious, 
and no cause of any kind could be elicited. The child had 
never walked. 

The disease, as it is found in children, is more general 
than in adults, and in many cases the rigidity is to be noticed 
in all parts of the body, or, at any rate, in all four extremi- 
ties. One side may be more markedly affected than the 
other. The cause of the spasm would in many cases appear 
to be due to uncontrolled reflex action, for directly the child 
is touched or startled in any way, all the muscles of the 
body start into a tonic spasm for a few seconds, and gradu- 
ally relax, the process being repeated over and over again, 
till the centre becomes temporarily exhausted, and the same 
stimulus fails to act so completely. 

These cases are sometimes, probably always, due to some 
central lesion. They are rightly called hemiplegic, in the 
sense that one side is often worse than the other, and the 
evidence is in favor of some one-sided lesion of the brain. 
In this respect they are evidently of the same class as the 

45 



534 THE DISEASES OF CHILDREN. 

post-hemiplegic disorders of later life, but these are uni- 
lateral ; in young children they tend to be bilateral. This 
difference probably finds its explanation in the time of life 
at which the lesion occurs. Now as at later dates, injury 
to the brain causes loss of control over the opposite side of 
the cord, and that half thus becomes more dominantly 
reflex than it should. The nerve-cells thus acquire a habit 
of quick discharge, and the blood supply necessarily 
becomes altered to meet the altered physiological needs. 
In the state of development such as now exists, it is impos- 
sible but that the fellow half of the cord should feel the 
influence of this uncontrolled action, and it also becomes 
timed to act in a similar way, although to a less extent. 
Thus the diseased action becomes more or less general. In 
the fully trained adult cord there would, at any rate, be less 
risk of such perverted action occurring, and, as a fact, it is 
not common. But in adults we associate this action on the 
one side with a degenerative change in the antero-lateral 
tract of the cord corresponding. Whether this is present 
in children is not known, but it seems hardly likely, at any 
rate in those cases in which it is associated with a microce- 
phalic brain. Perhaps it is, as Erb suggests, that the normal 
strands in these cases are never properly developed. It 
does not appear to me, however, that any hypothesis of this 
kind is necessary ; we have already a sufficient explanation 
in the damaged condition of the cerebral cortex, with its 
consequent deficiency of intelligence and control ; given 
this, and the functional development of the cord becomes 
arrested at the primitive stage of reflex action. The muscles 
are in consequence improperly controlled, irregularly exer- 
cised ; there is no harmony between the groups of muscles 
for complex action, they lapse into a state of spasm or con- 
tracture, and we have the very conditions with which we 
are concerned. Moreover there is one important fact about 



MOTOR DISORDERS. 535 

these cases which seems to point in this direction — viz., that 

some of them improve very much as they grow in years. 
Case I is now ten-and-a-half years of age. He is much 
more intelligent, has learnt his letters, and can walk about 
very fairly, though he is clumsy with his feet. And I have 
watched an almost exact counterpart in another boy from 
infancy, till now when he is nine years old. I should add 
that the other symptoms are somewhat variable in these 
cases — in some there is muscular atrophy, in others none; 
in one or two the muscles have seemed to be replaced by fat, 
as in the pseudo-hypertrophic paralysis; and in some the 
eyes may be affected with cataract, retinitis pigmentosa, or 
choroiditis with atrophy. 

Prognosis. — This cannot be very hopeful; nevertheless, 
with much patience and attention, children may and do 
improve considerably. There is not, however, so far as I 
know, much chance of their being other than imbecile, and, 
even if at first the disease is not associated with epilepsy, 
there is a strong probability of its developing as puberty 
approaches. 

Treatment. — But little can be done medicinally. If there 
is any definite lesion, iodide of potassium or iodide of iron 
might possibly prove useful, and bromide of potassium and 
sodium, or one of these combined with the iodide, may be 
given to control the fits. All possible practice should be 
given to walking, and to as many definite muscular move- 
ments as possible. Regular daily shampooing is also of 
service. Electricity has not seemed to me to be of much 
benefit. 



536 THE DISEASES OF CHILDREN. 



CHAPTER XXXIX. 

INFANTILE CONVULSIONS— EPILEPSY— NIGHT TERRORS. 

Infantile Convulsions include, besides severe and general 
convulsions, many cases* of local convulsive spasm or 
rigidity, such as strabismus, laryngismus, and that rigid 
inturning of the thumbs upon the palms and rigid flexion 
of the feet which have received the name of tetany, or 
carpo-pedal contractions. There is no essential distinction 
between infantile convulsions and epilepsy, so far as the fit 
is concerned ; the difference lies in the temporary character 
of the one and the chronicity or tendency to recurrence of 
the other. Nor will it do to push this difference too closely, 
for infantile convulsions may last, if not treated, for months. 
On looking over my notes, I find a tendency to class all 
convulsions under two years of age as " infantile," and all 
over that age as epilepsy, but in the epileptic cases are sev- 
eral in which the fits have continued since infancy. Per- 
haps this fact may have its instruction for us. The chronic 
tendency to convulsions which we call epilepsy unquestion- 
ably has much of habit in it ; each additional fit that comes 
makes the brain more prone to another, and it may well be 
that the convulsions of dentition, unchecked at their first 
onset, may in some cases become a confirmed habit, and 
thus chronic or epileptic. Eight out of twenty-six cases of 
epilepsy had suffered from infantile convulsions at an earlier 
date, and Dr. Gowers, working with much larger numbers, 
still makes the proportion as high as seven per cent, of all 
cases investigated, and he adds, it seems reasonable to ascribe 
to these convulsions of infancy a share in predisposing to 



INFANTILE CONVULSIONS, ETC. 537 

the convulsions of later life. Neurotic heredity, according 
to the same observer, is found in thirty-four per cent., the 
same as for the whole of life. 

The convulsions of dentition, no doubt in part influenced 
by hereditary tendencies, are yet, it is now generally ad- 
mitted — following the observations of Sir William Jenner, 
and later of Dr. Gee — largely associated with rickets ; and 
it is believed that the impaired nutrition of which rickets is 
the expression is productive of an irritable or unstable con- 
dition of brain, causing it to discharge itself spontaneously, 
or on what would otherwise be an inadequate stimulus. A 
certain proportion of cases is due to actual brain disease. 
Of 102 cases recorded by Dr. Gee, one-fourth were due to 
local disease, and the remainder to general causes. These 
include various conditions, but only one of any numerical 
consequence apart from rickets — viz., some acute exanthem. 
Reducing the number from these causes, fifty-six cases re- 
main, and every one of them was rickety. 

Convulsion, then, during dentition, if it be not due to the 
onset of an acute febrile disturbance — and even in such case 
it is still possible that the same condition may sometimes 
be at work — is one of the modes of expression of rachitic 
malnutrition, and this is really the important factor in the 
causation of the disease. It is quite unnecessary to take 
up space by enumerating all the secondary conditions which 
in this state will induce a fit. I would say, with Dr. Gee, 
that the convulsive diathesis affords an opportunity to a 
thousand irritants, natural and unnatural. The reader can 
readily fill in for himself some of these numerous local fac- 
tors — the dentition, the worms, the indigestible food, the 
excited play, the febrile state, and so on. 

Symptoms. — These are not quite the same in infants as 
in older children and adults. Infants are said to turn pale, 
to turn up their eyes, to get black in the face, to catch their 



538 THE DISEASES OF CHILDREN. 

breath, to become livid about the lips. Sometimes even 
babies will scream violently or give a cry before becoming 
convulsed. Sometimes they lose consciousness only, and 
wake up with a start. Once I noted insensibility, with a 
clonic convulsion of head and upper part of chest ; the chin 
on the sternum, and inspiration snoring. Laryngismus is 
common : sometimes there is tremor in sleep ; sometimes 
the whole body becomes stiff, and the breathing impeded, 
in a half-tetanic state ; sometimes even in infants the char- 
acter of the adult fit is maintained; there is the initial pallor, 
followed by lividity and convulsions — the fit commencing 
with a cry, and succeeded by somnolence. Lastly, may be 
mentioned twitching of the lips, half-closed and winking 
eyes, startings, and the condition of carpo-pedal contraction 
— the tetanie of Trousseau. In this condition the thumbs 
are bent rigidily across the palms of the hands, the sole of 
the foot is arched and the toes flexed. This state may last 
for many days, and remit and recur. Its importance is as 
an indication of the convulsive diathesis. It is a disease 
which occurs at all ages, but is far more frequent in infancy 
— according to Gowers, in the second decade of life also — 
than at any other period. In infancy it is more common in 
males than in females, and, as with convulsions, it keeps 
close company with rickets. 

Diagnosis, — The first point must be to search carefully 
for indications of rachitis ; their presence will tend to make 
one examine more critically the evidences of local disease 
which may present themselves. It will also be necessary, 
as far as possible, to assure ourselves of the absence of any 
acute exanthem. Very likely this will be impossible, for, in 
infants, pyrexia is quickly induced from numberless causes ; 
and the local factor which produces the convulsion will be 
liable to provoke febrile disturbance also. If an exanthem 
can be excluded, then there are the various local factors to 



INFANTILE CONVULSIONS, ETC. 539 

be sought, chief of importance being brain disease, such 
as meningitis from disease of the ear, hydrocephalus, and 
so on. Excluding these, as we probably may do, in the 
absence of any evidence of cerebral disease save the con- 
vulsions — and, perhaps, a bulging fontanelle, to which I 
have already alluded, as having but little significance neces- 
sarily attaching to it — we next examine into the question of 
teething, food, state of bowels, etc. ; and we shall by that 
time probably be in a position to form some idea of the 
cause of the convulsion in the case before us. 

Results. — Hemiplegia may follow an attack of convulsion, 
as I have several times seen. It should be only of tem- 
porary duration ; but should it not pass off, or should any 
rigidity come on, some local disease of the brain in all pro- 
bability exists. Children sometimes stammer and are stupid 
after a fit. In several cases of idiocy the history of a fit is 
the first note of evil. Strabismus appears to be one of the 
common results of convulsion, the pre-existence of hyper- 
metropia notwithstanding. 

Lastly, I may note the curious and interesting observa- 
tion of Mr. Hutchinson, that zonular cataract is a frequent 
associate of infantile convulsions and rickets. It may be 
congenital, therefore the accuracy of calling it a result may 
be questioned ; but it may also form after birth, and it usu- 
ally affects both eyes. 

Prognosis. — Many children die from convulsions at this 
early period of life; and frequent and violent convulsions 
must necessarily constitute a serious danger. This will be 
the more especially the case when dependent upon such 
conditions as the onset of scarlatina or measles, or the ex- 
istence of whooping-cough. In the case of local disease 
of the brain, including, as it does, meningitis of all kinds, 
tubercle, tumors, chronic hydrocephalus, etc., the disease 
can hardly be increased in gravity by the onset of convul- 



540 THE DISEASES OF CHILDREN. 

sions. But where it is associated with rickets, and the 
initial convulsions do not cause death, there is every hope 
that treatment will be successful in warding off their repeti- 
tion. 

Treatment. — In the actual convulsion what can be done 
should be done to stop it. This is not much ; but it is 
probable that the old-fashioned treatment, often called deri- 
vative, is of use, by lessening the turgid state of the brain 
which the fit produced, but which probably tends to prevent 
the restoration of equilibrium. To this end a warm or mus- 
tard bath is advisable, and an aperient should be given at 
once. Calomel is easy to administer, and is effective, and a 
couple of grains may be given to a child of a year old. When 
the child comes round, five grains of bromide of potassium 
maybe given immediately in some syrup; or if there is 
much somnolence after the fit, ten grains in solution may be 
given by enema. If this is unsuccessful, bromide of sodium 
may be substituted, or chloral combined with the bromide. 
As I have several times had occasion to remark, young 
children take both bromide and chloral well. Five grains 
of each may be given in combination to a child a few months 
old. If the convulsions be due to blood-poisoning of any 
kind, it is better to wait after the convulsions have subsided 
to see what course the case threatens to take. It need not 
necessarily be of greater severity because it has commenced 
by convulsions. Should it threaten to be so, quinine should 
be given at once. 

Epilepsy. — From the tables published by Dr. Gowers some 
very important facts are learnt concerning the disease as met 
with in children. Out of 1450 cases, 12J per cent, com- 
menced during the first three years of life; 5 J per cent, of 
the whole occurred in the first year; from then to five years 
the numbers fall, till at five the minimum Tor the early period 
of life occurs, only 1.7 per cent, beginning at that time. At 



INFANTILE CONVULSIONS, ETC. 541 

seven, the commencement of the second dentition, the num- 
bers rise again, then fall, and rise again, until at fifteen or 
sixteen the maximum for this period of life is attained with 
5| per cent, of the total numbers. Of those cases which 
occurred in the first three years of life, ascarides, sunstroke, 
falls, injuries at birth, are given as causes in a few cases; 
but the far larger proportion occurred during the first den- 
tition, and were attributed to teething; and the total num- 
ber of cases so caused may be put at 7 per cent, of the whole. 
If we further allow, as we can hardly escape doing, that 
rickets plays a large part in the occurrence of convulsions, 
and add other cases to those given in which rickets was 
probably present in early life, although the epileptic recur- 
rence did not occur till later, we have rickets playing the part 
of a predisposing cause in 10 per cent, of the whole num- 
ber. The neurotic heredity was in great measure transmit- 
ted from actual epilepsy (three-fourths of the inherited 
cases) ; but insanity was combined with it in a considerable 
number of cases. Of other diseases, chorea existed in other 
members of the family in numbers not far short of those of 
cases of insanity. 

Epilepsy is sometimes associated with malformation of 
the brain ; sometimes it comes on after hemiplegia, or blows, 
or a fall upon the head. 

Symptoms. — The chief feature of epilepsy is loss of con- 
sciousness, and this takes place in very varying degrees. 
Children will sometimes have a violent convulsion with bit- 
ten tongue, and insensibility, succeeded by stupor, as is so 
commonly seen in adults ; but a large number only faint or 
lose consciousness for an instant,* and -no more, but with a 
recurrence many times in the twenty- four hours. There is 
a sudden pallor, perhaps a momentary drop of the head, 

* Petit mal. — Ed. 

46 



542 THE DISEASES OF CHILDREN. 

while anything in the hand falls as from one momentarily 
overcome by sleep. The fits in children have a special ten- 
dency to occur by night. The nocturnal fits may consist of 
mere tremors, or the child may appear to be awake but with 
fixed gaze. It is perhaps convulsed, or laughs and talks in 
an idiotic manner. Observations as regards an aura are 
perhaps hardly reliable ; but I have several times elicited 
descriptions of giddiness and of disturbed sensations in the 
arm or in the fingers, and once in a girl of nine the fit regu- 
larly began by a complaint of abdominal pain. 

Diagnosis. — The paragraph relating to the diagnosis of 
infantile convulsions may be referred to. 

Prognosis. — This is neither better nor worse than it is in 
adults. A great many children improve under proper treat- 
ment, and the frequent recurrence of the fits is kept in abey- 
ance. When the fits are of recent origin, or have occurred 
but seldom, there is always a hope, to be encouraged in 
every possible way, that they may never recur; but, as in 
adults, there are also some very obstinate cases which resist 
all treatment. Some of the worst cases I have seen in this 
respect have been associated with confirmed hemiplegia, late 
rigidity, and so forth. If the fits are very frequent and in- 
tractable, there is a fear of imbecility following after. 

Treatment consists of attention to the child's hygienic 
condition, to see that his food is of proper quality, that his 
bowels are regular, sleep good, etc. For the arrest of 
the convulsions bromide of potassium is the most generally 
useful remedy. It may be given without risk (save with one 
exception) to the youngest children. At a year old we may 
begin at five grains three times a day, and even increase the 
dose if necessary. For older children, of ten and twelve, 
ten, fifteen, and twenty grains may be given three times a 
day. If this should not be successful, very likely the bro- 
mide of sodium will be so. I have sometimes thought that 



INFANTILE CONVULSIONS, ETC. 543 

the latter is more useful with children than the former. 
Sometimes the iodide combined with the bromide is useful. 
Bromide and digitalis, or bromide and belladonna, are good 
combinations when a neurotic heart is associated with the 
fits. Oxide of zinc is a good remedy for children, in three- 
or five- grain doses, and borax is recommended by Dr. 
Gowers. 

A child that has had epilepsy will require careful watch- 
ing at particular periods. The figures already quoted from 
Dr. Gowers show that both the second dentition and also 
puberty are times at which the disease is likely to show 
itself. Therefore the bromide should be resorted to if any 
threatenings occur. Mental study should never be allowed 
to proceed to the extent of exhaustion. Exercise should be 
abundant, and food nutritious ; while all things that make 
for a too continuous or excessive, and therefore morbid, 
nervous erethism, must be avoided or controlled. 

The one risk attaching to the administration of the bro- 
mide is its liability to produce lumps, or indurated, soft, 
,granuloma-like swellings over the body. The risk of this 
may be considerably lessened by combining some liq. arseni- 
calis, or liq. sod. arseniatis with it — this drug is very readily 
borne by children ; the bromide should never be continued 
for long periods continuously. 

Nightmare, or Night Terror, is a nervous affection of 
young children, and is allied to the much rarer phenomena 
of sleep-walking. It is also akin, I doubt not, to one form 
of nocturnal incontinence. All these conditions may be 
described as sleep disorders where cerebral under-currents 
seethe below a placid surface. Nightmare is usually sup- 
posed to have much to do with dyspepsia.* Henoch, how- 

* In mucous disease, although as a rule the nervous irritability is lessened, 
night terror is a very common feature in my experience; in chronic indiges- 
tion, too, nightmare and dreamy sleep, modifications of the same Symptom, 



544 THE DISEASES OF CHILDREN. 

ever, will not allow that food has anything to do with it, and 
I agree with him for the most part. The children in whom 
it occurs are usually quick, excitable, nervous children, and 
it runs in rheumatic and choreic families. It would be in- 
teresting to follow it up in relation to epilepsy and other 
nervous disorders. Of thirty-seven cases, there were twenty- 
one boys and sixteen girls, and nineteen of these had a family 
history of rheumatism ; some others came of a nervous or 
neuralgic stock. 

It is to be treated with bromide of potassium, or that and 
syrup of chloral, and in this way always subsides. It is a 
malady of little detriment in itself; but, as an indication of 
a nervous organization, it is most valuable. It is the 
" slacken speed " to the engine-driver which must never 
pass unheeded. 

are constant. I have also seen them rapidly disappear under a treatment 
directed to the removal of the catarrhal condition of the gastro-intestinal 
canal. — Ed. 



FUNCTIONAL NERVOUS DISORDERS — HEADACHE. 545 



CHAPTER XL. 

FUNCTIONAL NERVOUS DISORDERS— HEADACHE. 

Of other functional nerve disturbances in any marked 
form, such as are met with in adult life, childhood is not 
prodigal of examples. I have, however, seen functional 
vomiting and an extreme case, of functional hiccough, each 
in girls about twelve years ; and moderate hystero-epilepsy 
in girls of ten and twelve. In another girl of twelve there 
was functional paralysis of the abductors of the vocal cords. 
She had a fit in the out-patient room, and became insensible 
and rigid, but was not convulsed. She had also a croupy 
cough ; but on examining the larynx, which she very readily 
suffered, there was an entire absence of any morbid appear- 
ance, except in the position of the vocal cords. These played 
about somewhat close together during expiration, and during 
inspiration the anterior parts completely closed, the left over- 
lapping the right, and leaving only a chink posteriorly for 
the entrance of air to the lungs. The paretic state of the 
abductors was clear, and the functional character of the 
malady was equally so, for it quickly improved, so that in 
the course of half an hour it had almost disappeared. This 
patient had been in the hospital under Dr. Taylor for cata- 
leptic attacks, and, in one of her fits/ her eyes were first 
turned strongly to one side, and then she squinted. 

Twice I have seen hemi-anaesthesia with hemiplegia in 
boys of eleven or twelve. In the case under my own care 
I was at first disposed to think that there might be some 
actual lesion, notwithstanding the strong probability which 
experience teaches that, with complete hemi-anaesthesia and 



546 . THE DISEASES OF CHILDREN. 

hemiplegia, the condition is a functional disturbance only. 
But we subsequently learnt that the child was a regular 
vagabond, and his previous history, his habits, and the va- 
riability of the paralysis, made it conform to rule rather than 
to exception. 

The boy was twelve years old, with a neurotic family his- 
tory. The paralysis came on in a night, four months before. 
He had been a sharp boy, and had reached the highest class 
in the school ; but he had become dull and odd in manner, 
staying out all night, and being dirty in his habits. He had 
a markedly neurotic aspect — very dark, with deep-set eyes 
and small cranial development. He had a cunning appear- 
ance, yet had no air of imposture about him. His face was 
paralyzed on the right side, and the tongue deviated to the 
right side. The right arm was paralyzed, the extensors of 
the forearm most markedly so, and the wrist dropped as in 
lead-poisoning. He made evident effort to move it when 
told, but was obliged to call in the aid of the opposite hand. 
There was less decided failure in the leg, but when he 
walked his toes caught the ground in putting the foot 
forward — the knee was flexed, the heel drawn up, and the 
limb moved clumsily, as from want of harmony between 
the co-acting muscles rather than from actual paralysis, but 
the extensors obviously had the worst of it. The loss of 
sensation was complete, and thoroughly distributed to the 
right half of the body, mucous membrane as well as skin. 
The knee reflex on the paralyzed side was markedly exag- 
gerated. He was partially undressed for examination, and 
as I watched him in attempting to re-dress, whilst we went to 
the other children in the ward, he was evidently quite help- 
less as regards the right arm. The paralysis both of sensa- 
tion and motion — but the former far more than the latter 
— varied much from day to day ; and sometimes his special 
senses suffered, and he would become completely deaf on 



FUNCTIONAL NERVOUS DISORDERS — HEADACHE. 



547 



the right side, unable to smell with the right nostril, and 
wholly blind with the right eye. He could not then tell 
light from darkness, nor did he flinch when the finger was 
brought close to his eye. There were no morbid ophthal- 
moscopic appearances. Unfortunately he became so unruly 
and dirty that it became necessary to discharge him, and he 
was thus lost sight of, not much better than when admitted. 

Hysterical contracture will also be found sometimes in 
girls of eleven or twelve. Quite lately, a case of this kind 
has been under my care. It was speedily cured by keeping 
the affected arm firmly bound to the side, and compelling 
the use of the other. 

Headache is very common in children, from six years old 
and upward, and it arises from all sorts of causes. It is 
usually frontal and associated with sickness ; sometimes it is 
one-sided, over one or other frontal eminence, and occasion- 
ally disturbance of vision accompanies it, as in the megrim 
of older patients. 

Causes and Diagnosis. — It is not easy to distinguish be- 
tween the different forms of headache. Most commonly the 
child is said to be subject to sick-headache ; but, when the 
case is investigated — in one the ailment may be due to 
anaemia ; in another to indigestion or constipation ; in 
another it is the trait of a child of rheumatic parentage; in 
another, the result of hypermetropia. To arrive at an opin- 
ion in any case, it is well first of all to examine the eyes by 
the ophthalmoscope so as to eliminate the last-named con- 
dition. A large number of children are hypermetropic, and 
when they begin to tax their eyes for reading the strain 
upon the power of accommodation becomes excessive, and 
frontal headache arises, which may or may not be associated 
with internal strabismus. The headache is usually a supra- 
orbital one, and the letters run one into the other as the 
child reads. It is not unimportant to add that these cases 



:_lS THE DISEASES IF CHILD?/ 

are often distinctly worse when the health is deteriorated 
from any cause. The strabismus may, indeed, only be no- 
ticeable at such times — like the decayed tooth, which, though 
ed, aches only now and again, in response to 
impairment of the general health. In another large group 
of cases, the children are badly nourished and anaemic. The 
relation of gastric disturbances to headache is more open 
to question ; for it is certain that in many, perhaps most, 
cases of megrim, the stomach and brain react upon each 
other, and food will unquestionably excite an attack of head- 
ache, as a worm or other intestinal irritant will excite a con- 
vulsion. Headache is sometimes troublesome in girls at 
puberty, and tfa catamenial irregularity and 

backwardness. The headache of brain disease is likely to 
be occipital, unless it be cue to meningitis, when it is 
general. 

Symptoms. — Sick-headaches usually manifest some peri- 
odicity, though it may be but an irregular one. They are 
oftentimes attributed to food, and they are associated with 
vomiting. The headache is frontal, often of throbbing char- 
acter about the temples. The head is hot. and there is often 
some intolerance of light, or some hyper-sensitiv 
hearing. The victim is the subject of a terrible malaise, and 
for the time being only wishes to be let alone, and longs 
for sleep. The tongue is usually clean, the temperature nor- 
mal, and the pulse not quickened. The duration of sick- 
headache is variable. It generally subsides in sleep, and 
lasts but a few hours. Occasionally the vomiting is severe 
and repeated, and the child is out of sorts for some days. 
anaemic headache is less localized, more continuous, 
and perhaps less often associated with sickness. In most 
cases of headache the bowels are irregular. 

Diagnosis. — The ailment being a common one, there is 
some overlooking the headache of organic disease. 



FUNCTIONAL NERVOUS DISORDERS — HEADACHE. 549 

It will be well, therefore, to remember that bad headache 
sometimes ushers in typhoid fever — one of the common dis- 
eases of childhood — and that the headache of meningitis is 
usually associated with pyrexia and constipation, as well as 
its own more special symptoms. The hypermetrophic head- 
ache may be suspected if there be hypermetropia, and the 
anaemic, rheumatic, and other forms must be diagnosed by 
reference to the appearance of the child, its past history, its 
family history, etc. 

Treatment. — Headaches are usually troublesome, for 
several reasons. They are common, are not thought much 
of, and their excitants are not therefore avoided as they might 
be ; moreover, they are not immediately amenable to rem- 
edies — in many cases they hardly appear to be influenced at 
all — and the child slowly " grows out of them." The hyper- 
metropic headache must be treated by the ophthalmic sur- 
geon (not by the spectacle-maker), who will see that any 
anomalies of refraction or in the shape of the eyeball are 
properly corrected by carefully adjusted spectacles. Apart 
from this special form, all headaches are likely to be ren- 
dered less frequent by the prolonged use of such drugs as 
arsenic and iron, but they must be given for some weeks 
continuously if they are to produce much effect. In the 
headache of girls at puberty, perhaps iron, permanganate of 
potassium, and bromide of ammonium are most useful. For 
the attack itself, bromide of potassium may be given ; it is 
sometimes successful in relieving the throbbing forms of 
sick-headache. Guarana and tonga are sometimes useful, 
although not easily administered. Guarana may be admin- 
istered as an elixir (Martindale), the tincture of guarana being 
mixed with equal parts of simple elixir (F. 44), and half a tea- 
spoonful or a teaspoonful given, in water, for a dose. But, 
upon the whole, sleep is the best restorative, and arsenic the 
most reliable tonic for keeping the attacks at bay. 



y : D THE DISEASES OF CHILDREN. 



CHAPTER XL I. 

IDIOCY AND CRETINISM. 

Idiocy is met with at any age, from a few weeks after 
birth onwards. Imbecility is a condition of many grades. 
In some there is but slight departure from the healthy con- 
dition ; some are for long unable to walk or talk ; the worst 
cases have no natural sense of any kind. Twice only have 
I seen anything in the nature of cretinism amongst my own 
cases. Of nineteen cases, five were uncomplicated. In one 
there was a peculiar condition, which I could only denominate 
:h idiocy. The child, aged five, seemed fairly intelli- 
gent, although mischievous. She appeared to understand 
in a measure what was said to her, but her utterances in 
return were quite unintelligible. Two were deaf mutes ; 
five were more or less amaurotic (only one of these had had 
fits) ; one had white optic discs ; one retinitis pigmentosa ; 
one a peculiar stippled condition of choroid (? choroiditis); 
and the other two were amaurotic, without visible change 
in the fundus oculi ; four others had had fits ; and two were 
cretins. 

Idiocy may be either congenital or acquired. The con- 
genital cases are likely to be microcephalic. Acquired 
idiocy is common after convulsions. It is in many c 
impossible to say whether the two forms are alike due to 
some cerebral lesion or whether the one is dependent upon 
brmation rather than disease; but in some cases the 
history of sudden convulsion, one or many, is precise, as 
also that progressive impairment of intellect has followed. 
Idiocy may be compassed in a variety of ways at this early 



IDIOCY AND CRETINISM. 55 I 

age, in some by lesions which deprive the child of impor- 
tant channels for the acquisition of knowledge and experi- 
ence, such as sight and hearing, in others by damage to 
the cerebral cortex ; but the frequency with which convul- 
sions are spoken of as an initial symptom seems not unlikely 
to point to meningeal or inter-arachnoid hemorrhage, and 
subsequent pachymeningitic changes, as a common method 
of causation. Other cases there are, called by Dr. Langdon 
Down " developmental," where the disease comes to chil- 
dren who have at first evidenced an average intelligence, at 
the period of the first or second dentition or at puberty. 
Such children develop up to a point, and as a result, perhaps, 
of a fit, or some greatly impaired nutrition, such as may 
show itself by chorea, they become imbecile, and the brain 
undergoes no further development. 

Cases of this kind, and congenital idiocy probably, find a 
predisposing cause in consanguineous marriages and in 
alcoholic excess in either parent. The developmental form 
is possibly sometimes to be attributed to masturbation. 

Cretinism, as commonly seen, is a disease which is 
endemic in certain parts of certain countries. In Europe, 
it abounds in Styria and the Tyrol, and it is not uncommon 
in the Swiss valleys, Savoy, and Piedmont. It is occasion- 
ally seen in England, in the dales of Derbyshire and York- 
shire; but in this country it is more generally known as a 
sporadic affection. Happily it is not common. Those who 
have charge of large asylums for idiots see most of it, and 
Dr. Fletcher Beach, of Darenth Asylum, has published 
some interesting cases. Dr. Hilton Fagge was the first in 
this country to call attention to sporadic cretinism, in a very 
valuable paper in the " Transactions of the Royal Medico- 
Chirurgical Society." 

It is a curious and interesting disease, so strangely con- 
tradictory is it in its external form ; for in many respects 



552 THE DISEASES OF CHILDREN. 

age comes to the features in babyhood, while the blight of 
babyhood, in its weakness, imbecility, and puniness, settles 
upon the corporeal form, and withers the opening mind. 
The appearance of these cases is very characteristic. They 
cease to grow in very early infancy, and year after year they 
change so little, that the child of two or three remains 
much the same at eight or ten. In my own two cases, a 
girl of nine and a boy of fourteen have hardly altered, the 
girl since she was four, the boy since three. They have a 
yellowish chlorotic aspect, their skin is thick, harsh, and 
wrinkled, and the subcutaneous tissues in some parts seem 
almost cedematous, the eyelids being particularly puffy. 
The scalp is also noticeable for its harsh, scaly condition, 
and the scanty growth of coarse hair upon it. The head is 
flat, the forehead small, the face large. The limbs are 
large, the hands and feet flattened out, the abdomen large 
and pendulous, the tongue seems often too large for the 
mouth, and lolls from the open lips and teeth ; the teeth are 
irregular, deficient, stunted, and decayed. The thyroid has 
usually been said to be enlarged, but in some cases of 
sporadic cretinism it has certainly been wanting, and in 
others it has probably undergone atrophic or destructive 
changes. Attention, too, has been called to the existence 
of pads of adipose tissue in the triangles of the neck. They 
are often of considerable size, but I do not know that they 
have any further significance than as a part of the general 
tendency which exists in these cases for the development of 
an excess of subcutaneous tissue. 

Causes. — Consanguinity in the parents and alcoholism 
have been thought to predispose to a degenerate state of 
nervous system which may develop into cretinism, as into 
other forms of idiocy. But from the fact that it is a disease 
which attaches to particular regions, it seems clear that 
geological conditions play an important part in its produc- 



IDIOCY AND CRETINISM. 553 

tion, and of these the existence of magnesian limestone in 
the soil is generally considered to be the most important. 
It is said that infants are liable to become cretins if taken to 
reside in districts in which cretinism is endemic. 

The tendency which the same geological conditions have 
to produce goitre, and the frequent co-existence of the two 
diseases, have long been a matter of interest, and the re- 
lation between the two a subject of speculative inquiry. 

A further point was made when Dr. Hilton Fagge showed 
from dissections that in some cretinous children the thyroid 
body is absent. We do not yet know the full bearing of 
these facts ; but of late it has been asserted by Kocher that 
cretinism has supervened in adult life upon extirpation of 
the thyroid ; and in one or two cases of myxcedema, which 
is a cretinoid state supervening in adult life, the thyroid 
body has also been found to be atrophied. These observa- 
tions go to show that the perfect functions (not alone devel- 
opment, for the disease may apparently be produced after 
the brain has developed) of the brain are in some way 
dependent upon the integrity of the thyroid — a most impor- 
tant fact if it can be shown to be true. It is probable, how- 
ever, that cretinism owns many causes, hereditary, environ- 
ing, and possibly personal, and at present we are not in a 
position to speak very positively about it. 

Morbid Anatomy. — The bones of the skull are thick, the 
sutures abnormally obliterated, and the various foramina are 
liable to narrowing. Great importance is attached by some 
to premature union of the basal sutures, by which it is not 
unreasonably supposed that the growth of the skull, and, 
therefore, of the brain, would be seriously interfered with. 
The condition of the long bones is also peculiar; their car- 
tilaginous ends being enormously out of proportion to the 
stunted shafts. 

The Diagnosis of cretinism, or of idiocy, can give but 
little trouble. 



554 THE DISEASES OF CHILDREN. 

Prognosis is bad in cretinism. In idiocy it will depend 
somewhat upon its degree. Dr. Langdon Down states that 
the worst cases are those of accidental origin. More is to 
be expected to result from training in congenital cases, and 
which are prima facie worse looking, than in the possibly- 
more hopeful appearance of the child who is imbecile from 
disease. 

Treatment, — With the exception that cretins must be 
removed from any place in which the malady is endemic, 
and taken to dry and porous soil, the treatment of all forms 
of idiocy is much the same. A diminished brain capacity 
is the malady ; to make the most of the little that is left is 
the aim of treatment. The individual is less highly endowed 
than ourselves ; he is in a lower grade ; he needs to be 
studied. He has to be educated, and it becomes the busi- 
ness of his instructor to instil habits of order, cleanliness, 
and obedience ; to discover his likes and dislikes ; his most 
sensitive nerve strands and centres, and generally to work 
along the lines of such senses as retain the most perception. 
Idiots must be educated objectively. They are to be made 
happy by every possible means. And to this end their 
surroundings must be pleasant ; they must have a teacher 
whom they love ; and their eyes, ears, and hands must be 
taught to carry instruction. A knowledge of color and 
form can be brought home to them through the eye, and 
thus some of the fond memories and instant pleasures with 
which the beauties of Nature are associated ; music may be 
made to charm the ear, and, making resonance amid the 
trembling strands, tone into life some pulses of thought ; 
while the hand, by judicious exercise, may be made apt for 
various arts. It is by the application of means like these, 
backed by indomitable perseverance, and a capacity for see- 
ing in the but slow progress of the day or of the year a 
comparatively bright future, that a success that must be 



IDIOCY AND CRETINISM. 555 

called wonderful has been achieved at such institutions as 
Earlswood and Darenth. The education of the weak- 
minded must necessarily for the most part fall to such as 
have specially qualified themselves and who are specially 
apt. Patience, perseverance, and ingenuity in the opening 
up of fresh channels of instruction are the great requisites, 
and a somewhat uncommon combination of mental endow- 
ments in the instructor is necessary to command success. 
Nevertheless, these cases will, under favorable circumstances, 
and with the requisite attention, improve much even in 
home life ; and this hope is to be strongly impressed upon 
the parents, or those who have the charge of such children, 
as the motive for that continuous training which alone can 
enable the child to make the most of its diminished capital 
of brain power. Medically, there is not much to say, but 
that littler is important. Mens sana in corpore* sano is old 
and true ; but here the converse is the more important 
truth, that the mind being feeble, the bodily nutrition and 
reparative power are feeble. Imbeciles require warmth, 
they require to live on a dry porous soil, to be guarded 
against sudden atmospheric changes, and to be fed well. 
Except in so far as idiocy is occasionally seen in an early 
condition, dependent upon brain disease, syphilitic or other, 
or upon some neurotic state, such as chorea, it does not call 
for any special treatment in the matter of drugs. 

It is in one or other of these two conditions, idiocy and 
cretinism, that pronounced mental disease comes perhaps 
most frequently under notice ; but there are other less defi- 
nite conditions which are far more common — children not 
idiots, yet low, cunning, mischievous, and tiresome. Moral 
insanity West calls such aberrations, and a very good name 
it is. Others are stupid above measure with books, but 
sharp with tiheir fingers, or with some sense or other. All 
these require to be carefully studied, for there are few who 



556 THE DISEASES OF CHILDREN. 

have not some doors open by which their moral culture 
may be raised if we will but carefully search for them. 

Another common form of neurosis is passion. A little 
excitement sends such children into a fury, so that they 
become dangerous to their playmates. More or less this is 
a very common form of mental disorder, and it is very 
closely associated with bodily disorders. The child is 
worse when it is poorly, and the outbursts of excitement 
tend to react upon the bodily functions, and thus to make 
their disorder worse. 

Some children are melancholic. I have seen marked 
cases of this sort in boys and girls, the latter more often. 
Melancholic children are usually anaemic and haggard look- 
ing, and decidedly improved by good feeding and absolute 
rest of mind and body. If there be any difficulty in their 
taking a requisite quantity of food, they must be dieted 
strictly, and made to take what is ordered. Such are fit 
cases for Weir Mitchell's plan of treatment, which has been 
so successfully advocated in this country by Dr. W. S. 
Playfair for neurotic women. 

Chorea Magna, so-called, is also a mental disorder. It 
is not one that English physicians see much of. It has 
many resemblances to some of the more frenzied states of 
hystero-epilepsy that are happily but seldom seen in this 
country. The affected child becomes quite maniacal, and 
performs all sorts of antics; dances, sings, declaims, or falls 
into a state of epileptiform convulsion, or of cataleptic rigid- 
ity. It is a disease which is likely to come on as puberty 
approaches, but sometimes occurs in precocious girls from 
ten years old and upwards. It must be treated by the 
administration of such drugs as iron, bromide of ammo- 
nium, oxide or sulphate of zinc, and arsenic, the patient 
being under judicious management away from her friends. 



CHOREA. 



557 



CHAPTER XLII. 



CHOREA. 



I shall commence my description of chorea by what may 
be considered a typical case, which was not long ago under 
my care in Guy's Hospital, and which has the advantage of 
an exceedingly good report by the clinical clerk, Mr. 
Braddon. It is that of a girl aged eleven years, a thin 
anaemic child, with thick red hair and vacant expression. 
She had never been ill, but was always considered delicate. 
Her father was killed by an accident eighteen months before 
her admission ; twelve months later her brother died ; and 
eight weeks before her present illness, she, a girl of eleven 
only, had to " nurse " her mother through an attack of 
rheumatic fever. During this time she had complained of 
pains in her limbs and back, was feverish, and took to her 
bed for two or three days ; and from that time she grew 
duller, apathetic, and lost her cheerful manner. A month 
ago she was scolded by her mother for clumsily upsetting a 
cup, and it was then first particularly noticed that the move- 
ments of her right hand were ill-conducted, and that she 
was always twitching the right side of her face. Her right 
foot next became unsteady, and these irregularities pro- 
ceeded gradually to constant convulsive jerks and twitches 
of either, but more particularly of the right side of the 
body. Five days before her admission, a game-cock flew 
at her, and frightened her so that she moped by herself and 
was speechless ; and, till her admission, her spasmodic per- 
formances had increased in violence, and her talking and 
gestures had become unintelligible to her mother. 

47 



558 THE DISEASES OF CHILDREN. 

She lies in bed with her head twisted on one side, and 
rapidly changing in position if she is observed. She opens 
and shuts her mouth, twitches up its corners, jerks her head, 
and snatches the eyes irregularly from side to side. Her 
arms are thrown constantly before her on the counterpane, 
with a tendency to place her fingers in any position but 
apposition, the forearm being mostly in a position of 
over-pronation. The left arm is less distorted in movement 
than the right. When asked to pick up a pin, an irregular 
series of muscular actions takes place, tending ultimately to 
the desired result, but in which there is a noticeable tendency 
to the use of the adductors in excess of the abductors, 
and the pronators before the supinators. When asked to 
sit up in bed, she does so by an alternating use of opposite 
muscles, working upwards spirally like an eel, her legs gen- 
erally crossed, but not much subjected to the irregular move- 
ments ; the abdominal muscles take a fair share in the gen- 
eral jactitation of the body. When spoken to, she first cried 
and then laughed ; she generally laughs, and at the same 
time the movements increase. She takes some time to gather 
head to answer r which she generally does with stuttering 
articulation and explosive manner. There was slight clonic 
response in the calf muscles on stretching the tendons, and 
the extensor tendon reflex was good, the superficial epigastric 
reflex being exaggerated. The heart sounds were sharp- 
sounding and unduly pronounced, but quite clear ; the pulse 
irregular, soft, ninety-six per minute ; a bruit de diable over 
the veins of the neck ; the bowels were rather confined, the 
tongue flabby and rather furred. She was treated by ten- 
minim doses of liq. arsenicalis, and kept in bed and fed well, 
and under this routine she soon became much quieter, and 
a fortnight after admission she was allowed to get up. On 
the sixteenth day she was still considerably choreic in both 
arms, and her heart was still irregular ; a decided but remit- 



CHOREA. 559 

ting short systolic whiff had come at the apex, and another 
in the third left interspace near the sternum and over the 
third rib. The second sound was very accentuated, and the 
closure of the valves could be felt in the second space. 

If the student studies this report, he will find not only a 
truthful account of a case of chorea, but also in every fea- 
ture that is described one of the common occurrences of 
chorea, whether it be the family history, the antecedents, the 
appearance of the child, or the distribution of the movement, 
the posture assumed, the state of the-mind, the behavior of 
the heart, or any other of the many small deviations from 
normal behavior of the viscera, which together make up the 
disease. He may learn from it that chorea is associated 
with rheumatism (a fact, however, which is disputed by one 
of the first authorities upon the subject), both by heredity 
and by the patient having suffered herself from that disease 
(the mother had had rheumatic fever, and in all probability 
the child herself). It is typical in the sex — chorea being 
far more common in females. Next it illustrates the rela- 
tion of the disease to fright, worry, and overwork. All these 
things are powerful immediate provocatives of choreic 
movements, but they are, in all probability, not by them- 
selves sufficient, in the absence of rheumatic strain or other 
predisposing nervous weakness. Next it may be noticed 
that the onset is slow. She is first dull and apathetic, next 
she becomes clumsy with her right hand, and the right side 
of her face is twitched, and so on, till the whole right 
side is affected, and her speech grows unintelligible. Her 
posture in bed is characteristic. Over and over again a 
choreic child will lie in bed, with head, and perhaps body, 
twisted to one side, in the condition of pleurosthotonos, 
and then change suddenly to an exactly opposite curve. 
How often, too, does a choreic child lie extended in bed, 
making all sorts of grimaces, with " its arms stretched out 



560 THE DISEASES OF CHILDREN. 

on the counterpane," with its fingers pointing in all direc- 
tions but the natural one of " setting " towards each other, 
and the forearms and arms so rotated inwards as to make 
the palms look outwards. The crying and laughing when 
spoken to, the attempts to protrude the tongue, ending in 
its sudden appearance and as quick retraction, a flash of suc- 
cessful effort, an accidentally conducted message amid the 
disturbance of the storm ; and lastly, to conclude this pre- 
liminary sketch, he may learn from it the not uncommon 
condition of the heart- — that its action is irregular, and that, 
in the course of the disease, there is likely to appear a soft 
systolic apex murmur, the characteristics of which are not 
sufficiently pronounced to enable one to say whether there 
is any organic disease of the valves or not. 

To define chorea is impossible; but Dr. Sturges has hit 
upon a definition which is picturesque and sufficiently true 
to the purpose when he says that " chorea consists in an 
exaggerated fidgetiness." This description is a valuable 
one, because it will serve to convey the fact that chorea is a 
disease of varied degree. Sometimes it is so slight that all 
that can be said is that this or that child is an unusually 
restless one. It makes grimaces, or has peculiar finger move- 
ments, or it can never sit still, and so on. Fidgety children 
require watching; more violent movements may come on 
at any time under favoring circumstances, and then they 
have chorea ; but it is merely a question of degree. As re- 
gards the movements, they are excessively irregular; they 
are as though the nervous current played about amongst the 
nerve-wires, and only now and again, by some determined 
flash of the sensorium, does the correct message find its way. 
But the disease tells most upon such muscles or groups of 
muscles as are most varied in their action — most under the 
influence of emotion, some say — and thus the muscles of the 
face and arms are those which suffer the most marked con- 
tortions. 



CHOREA. 561 

Chorea often affects one side more than the other, when 
it is called hemichorea. The left side, some affirm, because 
the left arm and hand are less under control than the right ; 
the right side, others say, for reasons presently to be men- 
tioned. When the disease is one-sided, it not uncommonly 
assumes the form of paralysis, and choreic children are often 
brought for treatment because one arm is paralyzed. The 
twitching finger, the shrug of shoulder, or the grimace usu- 
ally reveals the nature of the disease without trouble. But 
although chorea, more marked on one side than the other, 
is very common, hemichorea, in the sense of the movement 
being entirely confined to one side, is very rare, and I agree 
with Dr. Sturges that such a condition is almost unknown. 
Chorea is essentially a general disease, an exaggeration of a 
faulty habit of control, and, although most decided here and 
there, is present to some extent everywhere. In fifty-four 
cases I have particularly noted the distribution. In thirty- 
four it was general ; in thirteen more on the right side ; and 
in seven only more on the left. But there is no doubt that 
the one side or the other are less often prominently affected 
than this, for while most of the unilateral cases are noted, no 
doubt no definite statement has been thought necessary in 
many that have been generally distributed, and it is probable 
that as regards the total number of my own cases (141) those 
in which the disease is mostly confined to one side would 
not have to be materially altered. It will be noticed that it 
does not coincide with my experience that the left side is the 
more prone to suffer unduly. 

The evidence of cerebral disturbance varies much. Not 
uncommonly choreics look completely imbecile, and they 
mostly laugh and cry from trivial causes and in a peculiarly 
explosive manner. But it does not appear that the chorea 
is dependent upon any definite cerebral disease, for it often 
goes with a brain which gives but little evidence of disturb- 



562 THE DISEASES OF CHILDREN. 

ance, and in others imbecility and movements improve 
together rather as the bodily health improves. In a girl, set, 
eleven, lately under notice, it was remarkable how the disease 
seemed to resist all treatment for some weeks, when sud- 
denly, almost in a day, the child improved in appearance, 
the movements ceased, she began to get fat in the face, and 
then progressed uninterruptedly to recovery. 

The history of chorea as regards its course is often one of 
much monotony, and for this reason perhaps in general 
practice it often fails to obtain the requisite medical super- 
vision. It is difficult to say when chorea ends, and, conse- 
quently, to fix its duration. To be once choreic is to be 
always so to some slight extent, and, therefore, when the 
more violent movements are controlled, there is still a 
lesser range which is still choreic, and which must make 
one cautious in affirming a cure. It is no uncommon his- 
tory for such cases to run on for two or three months, 
although when they are taken into hospital they almost 
always rapidly improve. But this is only up to a certain 
point ; they then remain stationary, and the lesser move- 
ments 'of the choreic are often exceedingly troublesome. 

Six to ten weeks is usually given as the duration of the 
disease. 

Lingering, however, as chorea is, in childhood it very 
usually gets well. It is more liable to be fatal as puberty 
commences. Nevertheless, death-tables do not show this 
very well, because the disease is so much more one of child- 
hood than of adolescence, and although relatively the death- 
rate is small under fifteen, the aggregate equals that of the 
chorea of adolescence. By the records of Guy's Hospital, 
it appears that twenty-eight fatal cases of chorea have oc- 
curred in the last thirty years, the respective ages of the 
cases being as follows : 



CHOREA. 563 

Years . 5 . . 7 . . 8 . . 11 . . 12 . . 13 . . 14 
No. .. I . . 5 . . . I . . 3 . . 1.. 2 . . 1 

Years . 15 . . 16 . . 17 . . 18 . . 19 . . 40-50 
No. .. 1..1..1!'. 5-. 2.. 2 

I pregnant woman exact age not stated. 
I younger not stated. 

I have had two fatal cases in young children, of which I 
give the notes. They very well illustrate the fact that when 
a fatal event ensues it is usually by the supervention of high 
temperature, rapid emaciation, and exhaustion — sometimes 
by coma. And, at any time, if the disease is complicated 
with much peri- or endo-carditis. 

A boy, aged five, was apparently in perfect health till 
eight days before his admission, when he slipped downstairs. 
He did not appear to be much hurt, and had a good night 
afterwards. But the next morning there was some loss of 
power in his hands and difficulty in swallowing. Soon after 
he began to scream at intervals during the day and occa- 
sionally at night. He had had pertussis and measles, but 
not acute rheumatism, nor was there any history of rheu- 
matism, so far as could be ascertained, in his family. He 
was in an irritable condition, resisting examination, but 
quite sensible and answering questions. He stared about 
in a vacant way, and his face, arms, and legs moved in a 
choreic manner. He swallowed without difficulty, and there 
was no paralysis of the ocular or other muscles. His left 
knee was a little swollen and painful, and a loud systolic 
bruit was audible at the apex, and another, less marked, at 
the base. No subcutaneous nodules could be found. He 
was kept at perfect rest in bed, and fed well, an ounce 
of brandy being ordered likewise. But the temperature 
gradually rose to 103 , the movements became more 
marked, and deglutition was very much impaired. He was 
then ordered salicin gr. v. three times a day, and he was 



564 THE DISEASES OF CHILDREN. 

sponged occasionally; but he continued to sink rapidly, 
notwithstanding the administration of nutrient enemata, 
and subsequently of strong liquid nutriment, administered 
by catheter passed into the oesophagus through the nose. 

At the inspection there were general early pericarditis, a 
large fringe of vegetation round the mitral orifice, and 
smaller fringes on the aortic cusps. There was some bron- 
cho-pneumonia at both bases. The brain and spinal cord 
were apparently quite healthy. 

The other case was a girl of seven ; in some important 
particulars very similiar; there was the same, but more 
marked, rise of temperature ; the same inability to swallow 
as the case progressed. 

Rosa L., set. seven, was admitted on October 14, 188 1, 
and died on November 8, 1 88 1. The parents are healthy. 
They have never had rheumatism, but the maternal grand- 
father was rheumatic. Of three other children, one has had 
acute rheumatism twice. During the last six months she 
has complained of pains in her knees, which have never 
been swollen, and also of occipital headache. Fourteen 
days ago she became very excitable, and her hands began 
to twitch. She became gradually worse, and now the move- 
ments are universal and she cannot stand. There is no 
history of fright, but she passed a w 7 orm a foot long ten days 
ago. 

When admitted, she had severe general chorea — not 
marked on one side more than the other — without fever, 
and with normal heart sounds. She was ordered a tea- 
spoonful of aq. chloroformi ter die, broth diet, and was kept 
in bed. She did not improve, and, eight days after, her 
diet was increased by two pints of milk, and six drops of 
liq. sodii arseniatis in glycerine and water were ordered. 
Her milk was increased to three pints on the 28th, or two 
days later. 



CHOREA. 565 

The temperature, till now normal, began to rise, and on 
the 30th reached 102. 8°. She became very restless, the 
movements almost continuous, and she became unable to 
swallow. 

Nov. 3. — Decidedly worse. She is emaciating. Temp. 
1 03. 8°. The movements have eroded the skin of the back, 
and she was slung in a hammock. Subsequently some 
purpuric blotches appeared on her legs, she became coma- 
tose, and died on Nov. 8th, with a temperature of 105.4 . 
She was bathed before death to reduce the temperature, but 
without any appreciable result. 

Medicinally, succus hyoscyami and chloral were adminis- 
tered towards the later days of the illness. 

The inspection showed no morbid appearances, except in 
the heart and kidneys. There were subserous petechias all 
over the former, especially on the posterior surface of the left 
ventricle. The edges of the mitral valve were roughened, 
and to these were attached fibrinous warty vegetations the 
size of a pea. The kidneys contained infarctions. 

Of the thirty fatal cases, twenty-five were in females. 

Pathology and its Relations to Etiology. — With one ex- 
ception, chorea has no morbid anatomy. There is no one 
lesion of constant standing, save the fringes of vegetations 
which occupy the edges of the aortic and mitral valves ; 
but endocarditis, in the form of vegetations, is present in 
the greater number of cases. Of the fatal cases already 
recorded (thirty in all), these were present in twenty-eight, 
doubtful in one, and absent certainly only once. Their 
absence is quite the exception. The mitral was affected 
alone fifteen times ; both aortic and mitral valves nine times ; 
the aortic valves alone four times; and pericarditis occurred 
with the endocarditis six times. 

The constancy of these little growths upon the edges of 
the valves has led to a very direct, simple, and fascinating 



566 THE DISEASES OF CHILDREN. 

pathology for chorea, in the suggestion that it is due to 
embolism. The vegetations are, it is supposed, washed off 
the valves and carried into the smaller branches of the cere- 
bral arteries, and thus produce local anaemia, mal-nutrition, 
and degeneration of the cerebral cortex and ganglia, which 
lead to the loss of control over the muscles. In favor of 
this view it is said that the disease is often one-sided, and 
most often right-sided, as is the case in hemiplegia due to 
embolism, and due, it is thought, to the straighter course 
the arterial passage offers to the transit of emboli to the 
left side of the brain than to the right. Secondly, in capil- 
lary embolism lies a rational explanation of the imbecility 
which so often accompanies the disease ; and lastly, that 
the smaller vessels have actually been found to be plugged 
in chorea by several competent observers. 

But these various arguments are traversed in several ways. 
The preponderance of a right-sided affection, for instance, 
is denied by many; a strict limitation of the disease is un- 
doubtedly rare. Supposing that one or other side suffers 
more severely, the affection is, nevertheless, present in other 
parts to a less marked degree. And as to the unilateral 
intensity, Dr. Sturges, whose experience is very large, and 
whose observation has been so careful and candid that it 
may well outweigh much that might otherwise point to a 
conclusion opposed to his, gives the seat of onset as thirty- 
six for each side. Dr. Pye-Smith, in an analysis of the cases 
in the clinical records of Guy's Hospital, 1870-72,* gives 
thirty-three cases of tolerably limited hemichorea, fifteen 
right and eighteen left. Out of fifty-four of my own cases, 
in which the distribution was carefully noticed, it was right- 
sided in thirteen, and left-sided in seven ; and I think it prob- 
able that larger numbers would make it still more evident 

* Guy's Hospital Reports, ser. iii., vol. xix. 



CHOREA. 567 

that it has but little tendency to attack one side more than 
the other. Take, next, the fact that choreic children are, 
almost invariably, peculiarly and recognizably fidgety or 
nervous — physiologically unstable — and that the exagger- 
ated or pathological condition may be followed up step by 
step in association with excess of wear and tear, or in re- 
sponse to some sudden nervous shock. Next, if chorea be 
due to embolism, why is the heart-murmur produced late in 
the disease ? And, lastly, it may be asked, Why is chorea 
so uncommon in adults? Why is it relatively infrequent 
in children when compared with the frequency of endocar- 
ditis ? It can hardly be doubted that acute endocarditis, 
from whatever cause arising, leads not unfrequently to capil- 
lary embolism, though not, it would appear, to chorea. Con- 
siderations such as these make one feel sure that the theory 
of capillary embolism is quite inadequate to explain the 
larger number of cases of chorea, and we are quite prepared 
for what is found to be the case, that, opposed to such facts 
in favor of embolism as exist, is a large body of negative 
evidence, where the vessels have been examined without 
result. It seems to me that a study of this disease leads to 
the conclusion that it is one unassociated with any recog- 
nizable structural change in the nervous system — that it is, 
in fact, a functional disease. We see this in the antecedents 
of the child, both parental and individual — we see it in the 
disease itself, in the want of control, the emotional excite- 
ment, in some cases its relationship to hysteria, and its all 
but certain tendency towards cure. 

During the course of chorea, rheumatism sometimes super- 
venes, but in what proportion of cases I find it difficult to 
say, probably not a large one. I have already made men- 
tion of a case where the chorea was succeeded by rheuma- 
tism, and as the latter subsided the chorea returned. This 
subsidence of chorea at the onset of rheumatism has been 
noticed by many observers. 



563 THE DISEASES OF CHILDREN. 

Fibrinous subcutaneous nodules, described by Drs. Bar- 
low and Warner, are likewise found in some cases of chorea, 
as in acute rheumatism. I have only met with them occa- 
sionally. Dr. Hillier* records a very remarkable case of 
this kind, certainly one of the most extreme that has ever 
been recorded. 

Etiology. — Although its pathology can only be clothed 
in somewhat vague language, yet that hypothesis accords 
best with the facts of the case, which supposes the existence 
of some depressed state of nutrition of the intellectual or 
governing centres. What the relation of rheumatism to 
chorea maybe we do not know ; but, for my own part, I believe 
that rheumatism is an evidence, perhaps a cause, of an im- 
poverished cerebral texture — a texture which is inherently 
bad, or easily exhausted, and which then discharges inter- 
mittingly, erratically, and feebly. 

Chorea is far more common in girls than in boys — ninety- 
eight girls to forty-three boys, or close upon, but rather in 
excess of two to one. If we take the statistics given by 
Hillier, M. See, Pye-Smith, Sturges, and my own, 1374 cases 
in all, the proportion is as much as five to two. That it 
should be more common in females is only what was to be 
expected, seeing that it is a disease very closely associated 
with emotional disturbances, which are at all times so much 
more rife in the female sex. 

The age at which chorea is most prevalent is between 
seven and twelve, and there is no decided difference between 
boys and girls as to this. But above twelve it would seem, 
as has been pointed out by others, that the disproportion 
between girls and boys, already two to one, increases to 
three or four to one. The table annexed shows this at a 
glance : 

* Diseases of Children, p. 238, Case V. 



CHOREA. 569 

Age 3 4 5 6 7 8 9 10 11 12 13 14 Over. Total. 

Girls, 1 2 7 6 15 7 13 13 8 12 5 3 6 98 

Boys, 042246784131 I 43 

Total, . . . 1 6 9 8 19 13 20 2i 12 13 8 4 7 141 

The same facts also come out fairly well in the heart dis- 
ease of the choreic, as seen in fifty-nine cases. 



3 


4 


5 


6 


7 


8 


9 


10 


11 


12 


13 


14 


Over 





3 


3 





13 


3 


2 


5 


4 


7 


3 


3 


13 



[The season of greatest prevalence is the spring. It occurs 
with extreme rarity in negroes.] 

Chorea is very apt to recur again and again in the same 
individual. In nineteen of my cases it is noted as having 
recurred, and in several three or four times. I have several 
times had the same child under treatment on more than one 
occasion. 

There is a tradition abroad that chorea is likely to be set 
up in healthy children when they are associated with the 
choreic ; and in the familiar fact that when one person yawns 
others in his company are likely to follow, we have an ex- 
ample of unconscious imitation, such as the communication 
of chorea might be supposed to be. But there is no paral- 
lelism between the two. For whereas yawning is a perfectly 
orderly sensori-motor action, chorea is an irregular combi- 
nation of involuntary movements on the part of muscles 
which are for the most part habituated to perform move- 
ments entirely under the control of the will. One cannot 
conceive of the choreic movements being elicited by any 
mere sensori-motor disturbance such as starts a yawn, be- 
cause the movements are of parts which are specialized, and 
as such want the control of any one centre. Thus, although 
choreic children in some numbers are admitted into the gen- 
eral wards of children's hospitals, instances of contagion are 



570 THE DISEASES OF CHILDREN. 

rare indeed. I have never seen such a case. Dr. West and 
others have recorded instances, and no doubt they occur 
occasionally, but the risk is not great ; and when they arise, 
they do so probably because some choreically disposed child 
has become startled by the sight of the contortions of its 
associate. This is illustrated by the history of a case in the 
Evelina Hospital but a short time ago, a girl aged nine years. 
Her mother had chorea twice, once when ten years old, and 
again at seventeen, and seven years before she had had 
rheumatic fever. The child's father had had rheumatic fever. 
The first child had had rheumatic fever, followed by chorea, 
a year ago. The patient is the fifth child, and in February, 
1 88 1, had rheumatic fever. In June, 1882, and February, 
1883, she had chorea; the first attack was caused by fright, 
and now from this last attack a younger child has " taken " it. 

Chorea is not prone to occur in several of a family (I 
have noted this only three or four times in my series of 
cases), nor is chorea, as chorea, transmitted in any large 
number of cases. In three cases only of 140 had it existed 
in one of the parents in former years. It is well known to 
be very liable to recur when once it has existed. In fifteen 
out of the 140 it was a second, in two a third, in one a 
fourth attack, and in one there had been many. 

As regards the heart disease of chorea, somewhat contra- 
dictory statements are made. The balance of opinion 
seems to turn in favor of the larger part of it being due not 
to organic but to functional disease. I cannot agree with 
this: making all due allowance for muscular irregularities, 
and a consequent temporary valvular (mitral) incompetence 
— a condition which undoubtedly exists in some cases — we 
have still other facts to consider: e.g., that in fatal cases a 
fringe of vegetations, either upon mitral or aortic valves or 
upon both, is present in the majority of cases; and that a 
considerable number of cases of heart disease have pre- 



CHOREA. 571 

viously had no other disease than chorea, so far as is known 
(of 248 cases of heart disease in children, fifty-nine were 
attributed to chorea, fifteen, however, being due to disease 
the exact nature of which was somewhat doubtful); and 
that of choreic cases many in the long run suffer from defi- 
nite valvular disease. Moreover, the non-existence of a 
bruit is no proof of the non-existence of disease. I have 
several times seen the mitral valve fringed with vegetations 
in chorea, when no bruit has been audible during life; more 
than once I have seen fatal embolism under like circum- 
stances. It is most necessary to impress upon the student 
that the disappearance of a bruit is no proof whatever of the 
absence of organic disease ; for if such cases are watched, 
they will many of them show subsequent signs, by disturbed 
rhythm and altered quality of sounds, that the changes in 
the valves are slowly progressing, and I have no doubt 
whatever that here is one of the sources of some of the 
many cases of mitral constriction that come under our 
notice. 

Nevertheless, I would not altogether discard the notion 
of a functional affection of the cardiac muscle ; on the con- 
trary, I have no doubt whatever of its reality. Irregularity 
of action is a very common feature of acute chorea, and by 
this I do not mean a necessarily violent chorea; for it is well 
pointed out by Dr. Sturges, in his very masterly and philo- 
sophical essay on this disease, that the violence of the mus- 
cular movements has no correspondence with the frequency 
of the heart affection, and, as I say, it is well known that in 
chorea there is frequently an altered quality of sounds, or 
an alteration in the rhythm. The existence of such a con- 
dition has, indeed, not been without dispute, but I think 
there can be no doubt about it. The cause has also been 
the source of much discussion. We cannot go far wrong 
in considering it as due to choreic disturbances of the heart 



572 THE DISEASES OF CHILDREN. 

muscle, and to be essentially the same as chorea of any 
other muscle. It is of little moment whether the effect be 
a paresis of papillary muscle alone, as some have contended, 
or a more general affection. It is only necessary to re- 
member that the younger the child, and the more recent 
the case, the more likely is it to be present. It chiefly con- 
sists in a want of keeping time, the beats following each 
other at irregular intervals, or in an excited, or sharp, or 
sudden systole, which is less sustained than natural. The 
chief interest of this condition in a practical way is, how- 
ever, the bearing that it has upon the previous question, 
that of the existence of organic disease ; and it must be 
admitted that, given muscular irregularity, valvular incom- 
petence — particularly, of course, of the mitral or tricuspid — 
is likely to follow. Some have even suggested that, if we 
allow this, then the vegetations found upon the mitral valve 
in cases of chorea are the result of such regurgitation, and 
a sequence such as this, as an occasional thing, is by no 
means improbable ; but allowing all this, and important as 
it all is as regards the question of the relation between 
rheumatism and chorea; I still think it conclusively estab- 
lished that the issue of chorea, as regards the heart, is in no 
small number of cases organic disease. The figures are as 
follow : * — thirty-eight had permanent cardiac disease ; 
nearly all of them mitral disease; thirteen others had evi- 
dence of disease, but whether permanent or not is uncertain. 
I may add that of seventy-eight cases in which the heart is 
noted as being normal, thirteen had certainly had rheu- 
matism. 

Exciting Causes. — In five-and-twenty cases of the 141 
there was a distinct history of fright, and in six others the 

* I am not here including any case of heart disease attributed to chorea 
such as are some of the fifty-nine above quoted, but only such as I have my- 
self seen in chorea. 



CHOREA. 573 

child was noticed to be unusually timid ; in other cases the 
disease commenced after a fit, some exanthem, over-work, 
etc. Taking the figures of Drs. Sturges, See, Hillier, and 
Peacock with these, we have 670 cases, with 224 of them 
due to fright or some nervous shock or strain. This, prob- 
ably, is too low an estimate of mental shock, for of 126 
cases taken from the collective investigation records, sixty- 
six cases were attributed to causes of this kind. It is worth 
remark that, although there is in so many cases a definite 
history of fright, the onset of such cases is usually slow, 
and thus it happens that it is difficult in many cases to see 
any relation between the supposed cause and the effect ; and 
doubtless, for the same reason, it happens that a cause such 
as this is at times entirely overlooked. I am disposed to 
think that one frequent cause of fright or nervous shock in 
children which is liable to be overlooked in this relation, is 
nightmare. Nervous children are very prone to this affec- 
tion, and nothing is thought of it; but those who have ex- 
perienced its horrors — the palpitating heart of the awaken- 
ing, and the ecstatic relief which is then experienced, and 
remains with some for some time' afterwards — will know 
that, to an unstable nervous system, few things are more 
fitted to upset its balance and to induce chorea. And here, 
perhaps, I may introduce the question of the relation of 
chorea to rheumatism, because, although in the majority of 
cases, perhaps, the latter stands to chorea rather as a consti- 
tutional element which predisposes, yet in some it precedes 
the chorea and introduces it, so to speak, and may thus be 
said to cause it. The facts I have collected in relation to 
these matters are these : 



574 



THE DISEASES OF CHILDREN. 



Auto-rheumatic only .... 


14 


Auto-rheumatic with family history 


25 


Rheumatic family history only 


50 


Gouty " » « . 


2 


Choreic " " " • 


2 


Xo history of rheumatism known . 


37 


Xot stated ...... 


11 



141 



Thus, thirty-nine had had rheumatic fever, and fifty 
more had a history of rheumatism in some of their near 
relatives. 

There has been much discussion as to what the relation 
between these two diseases may be — whether, even when 
Ave take into account the average of rheumatism which 
belongs to every family, there is any abnormal frequency of 
rheumatism in choreic families. I cannot enter into this 
here. It will be sufficient to say that, after having gone 
carefully into the question, I believe some thirty per cent, 
of families taken indiscriminately are rheumatic, while for 
chorea the percentage is about sixty. I do not think chorea 
is always rheumatic — it is a common method of nervous 
breakdown in nervous systems of unstable build, however 
produced ; and a choreic child may as well be the offspring 
of the epileptic, neuralgic, gouty, hysterical, or passionate, 
as of the rheumatic. Choreic children are often anaemic, 
often spare, as if they had been living badly, though this is 
bv no means ahvavs the case. Sturges gives it as his 
opinion that the choreic child is not uncommonly healthy- 
looking. 

Prognosis. — This is, as a rule, favorable. The disease is 
troublesome rather than dangerous. Nevertheless, if the 
movements be very violent, if the temperature is high or 
slowly rises, if there be much peri- or endo-carditis, or if the 
disease assumes the form of general paralysis rather than 



CHOREA. 575 

that of jactitation, the case must be regarded with anxiety. 
Certainly such cases as show much imbecility, with inability 
to swallow food, are dangerous, and require the most careful 
nursing. 

Treatment. — Choreic children are some of the most fre- 
quent attendants at the out-patient rooms of hospitals. In- 
quiry generally elicits the fact that they have been under 
treatment for some time, rather getting worse than better, 
and the parents have become tired of the want of improve- 
ment. This is not because chorea is not bettered by treat- 
ment. Take any or all these cases into hospital, and in a 
very few days a marked improvement will be manifest. It 
is often said there is no treatment for chorea— it gets well by 
itself. It does nothing of the kind. Many a child will drag 
on and on in a most miserable state at its own home for 
weeks and weeks, getting worse rather than better, which, 
when taken into a hospital, rapidly improves ; and I believe 
that this is because many are content to give a choreic child 
this remedy or that of the many that have been recommended 
as valuable drugs, and there the treatment ends. Where lies 
the difference in the result ? Simply in this, that in hospital 
the child is kept in bed. Here is the first principle of treat- 
ment for all cases of acute chorea, the rest and quiet which 
bed offers. Other subsidiary details are by no means unim- 
portant ; regularity in the administration, suitability in the 
quality, of the food, and attention to the action of the bowels, 
are not to be neglected, but rest and quiet come before all 
things. The child should be placed in bed, and, if the move- 
ments are violent, it must be carefully protected by padding 
the adjacent sides of the cot, or in very bad cases the child 
may be slung in a hammock. The bowels may be cleared 
out with some compound decoction of aloes — some glycerine 
being added, as recommended by Mr. Squire, to make it 
more palatable — or by some jalapine (one or two grains) ; 



5/6 THE DISEASES OF CHILDREN. 

and, if the sleep is bad, some Dover's powder, chloral, or 
succus hyoscyami may be given at night-time. A full milk 
diet is ordered, and some malt extract. As regards drugs, 
if the case is in any way acute or violent, I order nothing, 
but the child is regularly shampooed twice a day for a quar- 
ter of an hour. This generally procures sleep ; and by means 
of it, the good dieting, and the regular method of a hospital, 
great improvement is soon manifest. When, under this 
treatment, the more violent movements are quieted, then is 
the time to commence with drugs. I think there can be no 
question that no one can claim any great advantage over 
another. Sulphate of zinc, gradually increased up to ten or 
fifteen grains three times a day, is, I think, a most useful 
remedy, though very old fashioned. Arsenic, gradually in- 
creased from seven or ten drops up to fifteen, or even more, 
is another ; and with these, and iron and cod-liver oil, it is 
best to content oneself. The more sedative drugs, such as 
the bromides, chloral, hyoscyamus, conium, are of little real 
value, save as occasional draughts for sleeplessness, etc., in 
the early days. Veratrum viride has been recommended as 
useful in chorea. I have tried it, but seen no benefit from 
its use. In the last three years all the cases of chorea that 
have come under my notice in hospital have been treated as 
follows : They have been put to bed and allowed simply to 
rest, with good feeding, for two days. At the end of that 
time massage has been commenced, and special diet ordered, 
as given in the appendix of formulae. This treatment is car- 
ried out for a fortnight or so, when they are allowed to sit 
up in bed, well supported by pillows, and perhaps play with 
toys. I am never in a hurry to get them up, if the case has 
been in any way a severe one. The muscular strength ap- 
pears to me to be recovered much better in bed, while it is 
remarkable how too early exertion will throw a case back. 
When up and about again, the arsenic or zinc and cod-liver 



CHOREA. 577 

oil should be continued for sometime, and the child guarded 
from any great excitement in its play. A quiet convalescent 
home or change of air is often advisable, and the parents 
must be instructed to be careful of the child for a long time, 
as the remaining choreic movements are liable to become 
aggravated, under even trivial excitement. 

[The value of arsenic is unmistakable. My plan, when the 
patient can be watched, is to begin, from the first visit, with 
a small dose of Fowler's solution, three drops three times 
daily for a child of seven years, and gradually increase the 
amount by the addition of one drop a day until puffing of 
the eyelids or vomiting and gastric pain show that the limit 
of toleration has been reached. It should then be discon- 
tinued for a day, and afterwards resumed, the quantity being 
continuously kept a little below the maximum dose, until 
convalescence is established. Subsequently small doses of 
arsenic with iron must be given for a length of time to ward 
off a return. This method with attention to diet and the 
functions of the body has always proved most satisfactory, 
and often acted with wonderful rapidity.] 

For choreic children, as a preventive, there is nothing like 
regular exercise, always short of fatigue. Gymnastics of all 
kinds are excellent, as are also exercises of any kind which 
tend to increase the voluntary control of the muscular sys- 
tem. Thus drawing, piano playing, or for younger children 
various kindergarten appliances, etc., are all useful, some 
for one case, some for another. 



57§ THE DISEASES OF CHILDREN. 



CHAPTER XLIII. 

RHEUMATISM. 

" The fundamental difficulty in discussing rheumatism 
consists in defining what we mean by it," writes Dr. Thomas 
Barlow, and, true as this is as regards adults, it is still more 
true of children, who comparatively seldom suffer from acute 
rheumatism in such a pronounced form as is met with in 
older people. Children, indeed, suffer from typical acute 
rheumatism, with its fever, its pain, its swelling of the joints, 
its sweating; but to circumscribe it by these limits only, 
would be to ignore the larger part of the field of its work- 
ings, and to form a most inadequate conception of what 
rheumatism is capable of doing in childhood, or what I shall 
venture to call the " composite " of that disease. 

Acute rheumatism in the adult we all know well. It is a 
disease which sends the patient to his bed for three weeks; 
which is attended with fever, with profuse sour sweating and 
miliaria; with swelling and redness of the larger joints of 
metastatic development ; with much pain ; and with, in many 
cases, acute peri- or endo-carditis and pleurisy, or pneu- 
monia. 

And the disease is found in children in like manner; the 
older the child, the more likely is it to be typical; but a 
classical attack of acute rheumatism may be found at any 
age. I have seen it as early as two years, and more doubt- 
ful cases even in children of two and three months only. 
The age at which the individual cases occurred is stated in 
the following table : 



RHEUMATISM. 579 



34567 
4 . . . 6 . . . 4 ... 11 ... 6 

10 11 12 Over 



But, speaking generally, children's rheumatism is want- 
ing in the severity of any one symptom, and its existence is 
often revealed by no more than one of many. There is but 
little fever — but, stay, we must hardly say that, for it is a 
common thing in young children to have a temperature of 
101 , or so, which, if not tested, would have passed for 
nothing for all the history that the doctor could obtain. It 
is probable, however, that the temperature is not often ab- 
normally high for more than a day or two. The profuse 
sour-smelling perspiration so common in adults is almost 
absent in children. Of sweating there is but little, and of 
acidity of smell, none. The pain is less severe, and though 
the patients fret, they move about. The joint affection is 
less severe, the swelling has to be searched for, and often it 
happens that the puffiness of one ankle, or wrist, or knee, 
associated with pain, when pointed out to parents, has been 
recognized, but thought unimportant. Supposing the illness 
is sufficient to keep the child in bed, it may still happen that 
only one joint is affected, and that with the slightest swell- 
ing and the faintest blush. 

There can be no doubt that a large number of children 
suffer from rheumatism in this way, and never go to bed at 
all ; others, perhaps, who are kept in bed for a day or two, 
yet never see a doctor; and, in either case, when, years 
afterwards, some old valvular mischief needs explanation, 
there is no memory of the pre-existence of any disease. 

But what is true of these symptoms is not true of the 
heart. It is an old and thoroughly acknowledged maxim 
that in rheumatism the younger the patient the more the 
risk of heart disease ; but more than this, since the tout en- 



580 THE DISEASES OF CHILDREN. 

semble of adult rheumatism fails in children, and this part or 
that is affected solely, so is it with the serous membranes of 
the thorax as well as with those of the joints. And though 
such cases are not common, an acute pericarditis or an acute 
pleurisy is sometimes the first and only evidence of rheu- 
matism. 

It is highly probable that an acute endocarditis may, in 
like manner, be the sole index of the rheumatic state. One 
might say that it certainly is so, but that from the nature of 
the evidence demonstration is less easy. Unless one has 
watched the onset of the murmur, it is often impossible to 
say what is its age. 

From this description it will be apparent that the rheuma- 
tism in children is apt to be expressed by very indefinite 
symptoms. If a child is suffering from acute pleurisy, for 
example, what is there in it which will warrant one calling 
it rheumatic ? Probably nothing. The significance of inde- 
terminate symptoms as indicating rheumatism has been 
shown by a careful study of life histories, and it is by this 
study in individual cases that a particular symptom will have 
to be judged. Acute rheumatism, therefore, is not common. 
It is represented in childhood by what are called growing 
pains, by a little transient swelling of one joint, by pleurisy, 
by pericarditis, by a progressive or persistent anaemia, which 
leads to a medical examination, when valvular disease is 
detected, and so on ; nothing pathognomonic of the disease, 
which is only to be correctly apprised by the most careful 
inquiries into the family history and the small ailments from 
which the child has previously suffered. 

It has been said that it is more common in girls than in 
boys, and in the sixty-nine cases just tabulated, forty-two 
were in girls, twenty-seven in boys. The attack appears 
most commonly as a general one — that is, localized to no one 
joint, and oftener by far in no joint at all, but being asso- 



RHEUMATISM. 58 1 

ciatcd with general pain or soreness all over. Again, taking 
the same series, I find twenty-six thus generalized, fourteen 
others in which the knees were chiefly at fault, fourteen 
where the ankles were swollen, three only in which the 
wrists were alone affected. But there are other complaints 
which ought to be mentioned. Thus, four cases com- 
plained only of extreme pain in the side, which, in the absence 
of local inflammations of pleura or pericardium, must, I 
suppose, be attributed to a rheumatic muscular condition. 
The neck was alone affected once, the pericardium alone 
once. I have no note of anything that could have been 
called meningitis. At the same time I have occasionally 
seen cases of meningitis in children with rheumatic family 
histories, which have raised, though unfortunately not solved, 
the question of a rheumatic meningitis. The fever has 
generally been of the most moderate, or at any rate has 
easily been controlled by drugs. In the last ten cases taken 
from my note-books, which are a very fair sample of the 
usual run of such cases, the longest duration of any rheu- 
matic symptoms was four days, except in two cases, where 
bad peri- and endo-carditis complicated the disease. Con- 
trary to the opinion of some, I should say that relapses are 
uncommon; but again I must add that this statement is 
based upon cases treated almost invariably by salicylic acid 
or its compounds. 

In making this statement I am speaking of such recur- 
rences of the disease as have some definite time-relation to 
the primary attack — that is to say, which occur within a few 
days or a week or two of each other; and I must also ex- 
clude what might perhaps be considered of the nature of a 
relapse, the onset of chorea as the rheumatism subsides. 
Children, like adults, once they have had rheumatism, are 
liable to recurrent attacks of pain of no great severity. As 
I have already said, these are by no means to be made light 

49 



582 THE DISEASES OF CHILDREN. 

of, since they possess a well-known tendency to associate 
themselves with lesions of the heart and its valves; but they 
are to be looked upon as of the nature of fresh attacks, or 
of the persistence of a status rkeumaticus rather than as the 
recrudescence of a worn-out malady. 

As in adults, but more commonly than in them, acute 
pericarditis and endocarditis (the latter far more frequently) 
are often associates of acute rheumatism. But for the reason 
already given that the rheumatism so often escapes notice, 
it is almost impossible to say what proportion of cases occur 
as the direct outcome of the one attack, or how far it re- 
sults from some persistent state which slowly and surely 
damages the valves. Of my series of sixty-nine cases of 
acute rheumatism, fifteen had organic disease, one aortic 
disease, two pericarditis, and the remainder mitral disease ; 
and five more had sufficiently pronounced symptoms of 
cardiac disturbance, such as alteration in quality of the 
sounds, displacement of impulse, irregularity of action, as 
to make it probable that there was also actual disease. 

Acute rheumatism is strongly hereditary. Of the same 
sixty-nine cases, thirty-two had a good history of rheuma- 
tism in close relatives, father, mother, or brothers, or sisters; 
nine more had a moderate rheumatic strain, the disease 
having occurred in uncles, aunts, or grandparents ; in four 
the history was vague ; seventeen had no ascertainable 
rheumatic taint; and no statement was made upon the point 
in seven. The' remarkable power of transmission which 
rheumatism occasionally shows is well illustrated by a case 
I published in the " Guy's Hospital Reports," vol. xxv., 
where, with a rheumatic strain both in father and mother, 
five out of a family of six children under fifteen, all but a 
baby of fourteen months, had either had rheumatism or heart 
disease. A boy of fifteen had had rheumatic fever twice, 
and had mitral regurgitation ; a second boy, aged ten, 



RHEUMATISM. 583 

was similarly affected ; the third, a girl, aged eight, died of 
mitral disease; the fourth, a girl, had rheumatic fever (after 
scarlatina), with subsequent progressive thickening of the 
mitral valve ; and the fifth, a boy, aged four, was laid by, all 
one winter, with rheumatism. Steiner gives a yet more 
striking case, where a rheumatic mother had twelve children, 
and eleven of them had had rheumatism before the age of 
twenty. 

But the larger part of the rheumatism of childhood con- 
sists of isolated, and, at first sight, disconnected, ailments, 
which must now be enumerated seriatim. 

Tonsillitis maybe mentioned first, because there is a grow- 
ing frequency of assertion that it is a rheumatic ailment, 
generally as preceding the attack. It is probably more com- 
mon in adults than in children. I have notes of only a few 
cases of the kmd. 

Next we may take chorea. This, as one of the most 
prominent of the diseases of childhood, has already received 
consideration on its own merits in the preceding chapter; 
but in relation to rheumatism it is important to bear in mind 
that it not uncommonly precedes, more often it succeeds, 
and occasionally it alternates, so to speak, with rheumatism. 
Cases occur where chorea is followed, and, in great measure, 
replaced, by acute rheumatism, and, as the latter subsides, 
the chorea comes back again. The actual figures have 
already been dealt with ; but I may say again that it appears 
to me that chorea has a relationship of some sort with rheu- 
matism in two-thirds of the cases ; but there is naturally a 
good deal of difference of opinion upon this point. 

Heart disease is another symptom of rheumatism. It hap- 
pens over and over again that a pale and emaciated child is 
brought for treatment. Mitral disease is detected, and yet 
there is no history of previous rheumatism. Inquiry reveals 
that one or other of the parents has had rheumatic fever, 



584 THE DISEASES OF CHILDREN. 

perhaps some one or other of the brothers or sisters also. 
We are fairly justified in regarding such cases — always sup- 
posing that the rheumatic attack has not been overlooked — 
as cases where the rheumatism has localized itself in a par- 
ticular part. In a few cases I have seen even young infants 
with heart disease, which, had it not been that there was a 
rheumatic family history, would have been supposed without 
question to be due to malformation. Pericarditis, in like 
manner, may be the primary disease, and the joint affection 
develop later, or not at all. As illustrations of these points, 
I may mention the following cases : 

An infant, aged two and a half months, ailing for four 
weeks. It was extremely pallid, with a cantering action of 
the heart, and a loud systolic mitral bruit audible all over 
the prsecordia, and in the axilla and back. Its mother had 
suffered from what was probably rheumatic fev^er when twelve 
or thirteen years of age. 

A boy of fourteen, with pains all over him, and extreme 
anaemia, was admitted for irregularity of the heart, and de- 
veloped an acute pericarditis without any definite rheumatic 
attack. 

Another boy, about twelve, was admitted for pericarditis, 
and developed a rheumatic affection of the joints some three 
or four days later. 

A girl, aged eight, with a rheumatic father, and who had 
suffered nine months before with rheumatic fever, was ad- 
mitted with left pleuro-pneumonia, followed within a few 
hours by pericarditis. She was in the hospital seventeen 
days, and had no joint trouble at any time. 

Acute pleurisy and pleuro-pneumonia are sometimes the 
symptoms of rheumatism. They are very commonly part 
of acute rheumatism; but I am now more particularly allud- 
ing to the fact that just as a pericarditis may be the only 
indication of rheumatism, so also may pleurisy or pleuro- 



RHEUMATISM. 585 

pneumonia. The case just mentioned is an illustration of 
this. 

As other features of a rheumatic attack may be mentioned, 
first of all, certain acute erythematous affections of the skin. 
Urticaria is one of these ; and for the rest, perhaps, erythema 
multiforme is the best general term, for the eruption is some- 
what diverse in appearance — now papular, now marginate, 
and occasionally associated with purpura. Next, there are 
the subcutaneous nodules, which have been described by 
Dr. Barlow and Dr. Warner. These are small inconspicuous 
masses, which occur mainly about joints. The back of the 
elbow, the malleoli, and the margins of the patellae are the 
commonest sites ; but search should also be made along the 
vertebral spines, the crista ilii, the clavicle, the extensor ten- 
dons of foot and hand, the pinna of the ear, the temporal 
ridge, the superior curved line of the occiput, and the fore- 
head. They may be solitary or in crops, are painless, and 
generally more palpable than visible. They appear and dis- 
appear in a few weeks, sometimes in a few days, and in rare 
cases persist for many months. They are fibrous, nucleated 
in structure, and some are possessed of considerable vascu- 
larity. These nodules are of considerable importance in two 
respects. In the first place, inasmuch as they undoubtedly 
occur in the course of, or as a sequel to, acute rheumatism, 
they may be of considerable use in establishing a diagnosis 
in doubtful cases ; and, in the next place, it has been shown 
by Drs. Barlow and Warner that they are almost invariably 
associated with disease of the heart, and more often than not 
with a progressive form of disease. 

There yet remain to be mentioned some few lesser ailments, 
which, whilst they do not appear to have any constant or 
even frequent relation with rheumatic fever, are nevertheless 
found in particular children, and sufficiently often, in those 
who have a rheumatic family history, to justify their inclu- 
sion in the composite of rheumatism. 



586 THE DISEASES OF CHILDREN. 

Children of rheumatic parentage are often habitually 
anaemic and thin. As a matter of practice, if I have to do 
with a child who is anaemic, thin, and of dark with- 

out any particular transparenc ; f skin, I ah 

inqu carefully into the family history, and I think 

that rheumatism taints more than an average of such. The 
rheumatic diathesis is sa ft some to be expressed by a fair 
complexion amongst other things. My own experience 
would lead me to say that a dark complexion was more 
prevalent But this is a question which depends so much 
upon what individuals consider to be evidence of rheumat 
that I do not propose : attempt to upset the generally re- 
d statement. 

Nervousness is entitle term, perhaps, but it is one 

in common use with parents, and ; f con- 

ditions which are important to note. Of these, a sub-choreic 
conditio:: A child is constantly fidgeting, or mak- 

performing irregular movements of his 
fingers or hands, or he is clumsy in his movement 
other has an irritable or exhausted ner\ ifter what 

to healthy children is moderate play. The nervous c 
becomes unusually excited while playing, perhaps suddenly 
bursts into a cry, or becomes ill-tempered without cause, or, 
after the ga:r i out, and wanting to lie 

down ; or may be he is actually languid and ill for some 

ds. Sleep com^ if at play 

wares their bedtime. They wake up fitfully, talking or 
aming. 

2v~htmare is another rheumatic a— It is v 

common — seventeen out of a series :: : :n owned 

a rheumatic parentage. 

Obstinate headache in children is frequently found in r; 

lilies. It is prone to be associated with the anaemia 
of which mention has already been made. Of thirty-three 



RHEUMATISM. 587 

cases of headache, twenty-three were of rheumatic stock, 
five of epileptic, and five only showed no abnormal taint. 

Stiff neck is another ailment quite common in childhood, 
and for which, perhaps, lumbago is substituted in the adult. 
Whether this be so or not, however, I should wish to teach 
that stiff neck, an ailment of childhood, and lumbago, one 
almost confined to adult life, are both diseases of the rheu- 
matic strain. Barlow suggests that the isolated phenomena 
met with in the rheumatic, and of which stiff neck is one, 
are the acute rheumatism of the adult distributed, so to 
speak, and it may be so ; but I cannot say that I have no- 
ticed the condition in those who have actually suffered from 
joint troubles or heart disease at any former period. Amongst 
other troubles which may be said to be of this sort, I have 
noticed spasm of other muscles, causing sometimes retrac- 
tion of the head, the peculiar inturning of the thumb upon 
the palm, and the toes to the sole of the foot, which is called 
tetany ; also muscular tremors of various kinds, stammering, 
and nocturnal incontinence of urine — all these things re- 
duced to their cause, or to come as near to it as may be, are 
nerve discharges, excited by morbidly slight stimulation or 
irregularity in the discharging act. And there is another 
feature of the rheumatic child which is no doubt allied to 
these — viz., a frequent stomach-ache soon after the ingestion 
of food. A number of such children tell a tale of pain dur- 
ing or soon after a meal, and this is often associated with an 
action of the bowels. Their food is said by mother or nurse 
to run through them. Now what happens is surely this, 
that the nervous supply to stomach and intestine is morbidly 
irritable and responds to the introduction of fresh food by 
excessive vermicular action. I may perhaps add, as part of 
the argument, that at little opium in the form of Dover's 
powder, almost certainly cures the complaint. 

Of skin diseases, psoriasis and erythema nodosum occur 



5 S3 THE DISEASES OF CHILDREN. 

in the rheumatic, and the latter in a peculiarly marked man- 
ner ; for of twenty-nine cases, nineteen were rheumatic, five 
only were certainly not so, five had not been interrogated 
upon the point. Allied, I suppose, to this affection is the 
purpura that occurs in the rheumatic, or the more definite 
.sis rheumatica which occurs in the form of crops of 
purpuric tingling papules. But this is more common in 
adults than in children, in whom I have but seldom seen it. 

Diagnosis. — There is less danger of rheumatism being 
mistaken than of its being overlooked ; but I have several 
times seen a rheumatic hip give rise, by the persistence of 
pain and absence of swelling, to the suspicion of early dis- 
ease of the joint ; and there are other affections of the bones 
and joints which sometimes lead to mistake. There^is an 
occasional acute suppurative disease of hip or knee in infants ; 
there is the acute inflammation at the epiphysial lines which 
takes place in infants with congenital syphilis ; there is the 
hemorrhagic periostitis which occurs in scurvy ; there is 
acute ostitis and necrosis with pyemia — that fatal disease 
which is so common in childhood and which is constantly 
mistaken at first for rheumatic fever ; there are the effusions 
into the joints which take place in bleeders (hemophi 
there is the pain and tenderness of rickets ; — all these, by the 
pain and immobility which they occasion in young children, 
may be thought to be rheumatic without much difficult}', if 
we are not on the look-out to discriminate between them. 
And again, as Barlow has pointed out, there is much in the 
early stages of infantile paralysis to liken it to acute rheu- 
matism. There is often fever and general tenderness in the 
affected limbs ; and Barlow records a case of a child in 
whom, for more than a fortnight, there was extreme tender- 
ness and a little redness and swelling of the dorsum of each 
foot. 

Having said this much, however, it mav also be su^ested, 



RHEUMATISM. 589 

though I would not say positively that it is so, that the rheu- 
matic state may act upon different individuals in different 
ways, and thus may produce, in some, effects which we are 
wont to attribute to other causes. I might illustrate what 
I mean by this very disease — infantile paralysis. Here is a 
disease which suddenly attacks healthy children with fever, 
and which ends in paralysis. We know absolutely nothing 
of the disease, except that it produces certain results. To 
any one who should affirm that infantile paralysis is due to 
the rheumatic poison we could say nothing, as we have no 
evidence for or against such an opinion, and clearly there is 
no reason why it should not take its place as one of perhaps 
a number of possibilities, luowever unlikely or small its 
chance, so to speak, may be. But the point of this is equally 
true as regards joint disease and serous inflammations in the 
rheumatic. We generally assume, in dealing with any de- 
structive joint disease, that it is not rheumatic, because it is 
a generally accepted maxim that rheumatic inflammations 
are prone to resolve. But if, as soon as we see a chronic 
synovitis or destruction of a joint resulting from it, we at 
once exclude rheumatism because of the condition, what 
chance have we of ever ascertaining the natural history of 
the disease? I believe that permanent disease in various 
parts is no uncommon result of an attack of rheumatism 
which has been overlooked. We allow this much without 
question as conclusively established in the case of the heart, 
but for pleura or joint no such teaching is accepted. I should 
like to see a revision of statements on this point, based upon 
a careful inquiry into the life history of the individual, his 
family history and antecedents, in all such children as are 
affected with chronic joint disease and empyema. Of course, 
such common affections are due to a great variety of causes, 
many of them in no way rheumatic, but I doubt not that 
rheumatic inflammation adds its quota to the total. 

50 



590 THE DISEASES OF CHILDREN. 

Of scarlatinal rheumatism I have already said all that is 
necessary (p. 187). If it be a distinct disease, the counterfeit 
is at any rate so like the original as to be undistinguishable. 
There is the same metastatic affection of joints, the same 
tendency to the occurrence of an endocardial murmur, the 
same relief by salicylic acid treatment. It differs in one or 
two points, perhaps, if the type of disease be drawn from a 
large number of cases, for there is but little tendency to peri- 
carditis; the endocardial murmur is prone to disappear — 
though this must not be taken to indicate that the bruit has 
been of a " functional " nature, and unassociated with endo- 
carditis — and there is some, though judged by its variety but 
slight, tendency to the occurrence of acute suppuration in the 
joints. These, however, hardly to my mind constitute any 
essential differences, and I look upon the disease as prob- 
ably acute rheumatism. I am the more inclined to do this, 
as several cases which have occurred to me have been in 
rheumatic families, and I am therefore disposed to believe 
that it is a constitutional trait, which develops itself under 
the altered condition of health produced by the scarlatina. 

Rheumatism has no morbid anatomy, save such as at- 
taches to the heart, and to this belong no peculiarities. But 
it may be said, in short, that acute rheumatism is fatal by 
its pulmonary and cardiac complications ; and that, when it 
is so, it is usual to find acute pericarditis and endocarditis, 
the muscular wall of the heart being pale, softened, and 
dilated; the weight of the heart is increased, and usually 
very much so, probably in great measure by acute inflam- 
matory swelling, and the lungs are in that peculiar con- 
densed, solid, sodden condition of leaden color, which has 
usually been called oedematous. This condition is com- 
monly double-sided, and is associated with more or less 
pleural effusion. 

The treatment of acute rheumatism follows the same lines 



RHEUMATISM. 59 1 

as the disease in adults. The child must be kept in bed, 
between the blankets or well covered in flannel, and any 
painful joints are to be swathed in cotton wool. The diet 
strictly farinaceous; milk and bread and butter, biscuit, etc., 
may be allowed. Since Dr. Maclagan first recommended sali- 
cin, all my cases have been treated either by it or salicylate of 
sodium, the latter far more often, on account of its cheapness. 
By its means the attack, if free from complications, has been 
a disease of comparative unimportance, and relapses have 
been almost unknown. Eight, ten, or fifteen grains may be 
given every three hours; ten grains is the usual dose for a 
child of eight or ten, and it is given with syrup and acetate 
of ammonium; this usually for three or four days, when it 
is reduced to three times a day, and then, after a week or 
so, combined with quinine. Should there be any pericarditis 
or acute endocarditis, the chest is to be covered with wool, 
or spongio-piline, or poultices, and small doses of opium, 
in the form of Dover's powder, given three or four times in 
the twenty-four hours. Three or four grains of the powder 
may be given to a child of six or eight, and belladonna or 
digitalis must be given if necessary, according to circum- 
stances. The salicylates are supposed to be inclined to dis- 
turb the hearts action, and are therefore sometimes discon- 
tinued when heart disease sets in ; it has also been stated 
that, after its onset, their continuance is unattended with 
good effects upon the rheumatism. I always give it with 
caution and careful supervision in such cases, but I am by 
no means disposed to withhold it, unless there should be 
distinct indications for doing so. But there is this to be 
said, that when the heart attack is severe, the joint affection 
is very slight, or none at all. The cardio-pulmonary condi- 
tion, which I have described above, is a most puzzling one 
to treat. The child lies propped up in bed, extremely pale, 
with dilating alas nasi and rapid breathing, the heart pump- 



592 THE DISEASES OF CHILDREN. 

ing away at 120 to 160 per minute; there is acute pericar- 
ditis and mitral disease also, though this is often uncertain 
from the confusion of sound produced by the pericarditis and 
the rapid action. The chest shows considerable dulness and 
high-pitched tubular breathing, probably from the seventh or 
eighth rib downwards, at both bases. In such cases it is 
very difficult to say what drugs do good, and whether a case 
is to do well or badly. Undoubtedly the most essential 
requisites are careful nursing and judicious feeding; these, 
and opium given internally, will steer many cases through 
the pericarditis — the heart's action quieting down, and the 
pleuritic effusion and solidification of the lung slowly clear- 
ing off. But there are, unfortunately, many cases, hot differ- 
ing much in the physical conditions ascertainable, in which 
the child becomes more restless, vomiting supervenes (one 
of the worst symptoms possible in cases of this kind), and 
the child dies quite quickly. These are cases in which 
brandy must be administered freely. Ether is, no doubt, a 
useful drug under these circumstances, but it is not one that 
children take readily, and it is often vomited, in which case, 
however, it may be injected subcutaneously. 

Regarding the treatment of the rheumatic child — whether 
it be rheumatic by any attack of former acute rheumatism, 
or its tendencies shown by some of the lesser ailments in- 
cluded in rheumatism and associated with hereditary taint — 
there is much to be said. Such children require the most 
watchful medical care, and much more than is usually con- 
sidered necessary by their parents — uninstructed, as most of 
them are, as to the meaning of trivial ailments in such chil- 
dren. A tonsillitis, a headache, paleness, etc., do not neces- 
sarily suggest the advisability of an examination of the 
heart; but such conditions in these children are to be 
looked upon as part of the life-history of rheumatism, and 
unless the heart be examined — shall I say, supervised (as 



RHEUMATISM. 593 

indicating the necessity for prolonged watchfulness") — disease 
may be creeping on where we least expect it. These are 
some of the cases where the doctor should be remunerated 
for keeping the child well, rather than called in to cure it 
when actually ill. His fee should be an annual retainer, 
irrespective of any illness, and there is no doubt that rheu- 
matism and its results would be diminished. The manage- 
ment of the rheumatic child requires discretion at all points. 
It is not only that its diet and its clothing require it, educa- 
tion and play alike call for advice in many instances, and the 
question of residence, although often quite beyond power of 
alteration, is one of vital importance. Of course, until we 
know what rheumatism is, we must deal to some extent in 
generalities, which may be very open to discussion; but 
with this admission, it may be said that warm flannel cloth- 
ing is essential ; the diet should be varied, and contain 
plenty of easily digested vegetables, in addition to the milk 
and ordinary food ; and both as regards work and play, the 
slightest indications of excess, in the way of exhaustion — 
whether this be temporary or continuous, any headache, 
tendency to nightmare, or what has been called nervousness 
— must lead to immediate moderation. For such children 
the greatest care should be exercised in the selection of 
a school, both as to a dry, warm climate, the home life 
therein, and the happiness of the child; and unless all these 
things are satisfactory, it is far safer to keep the child at 
home. 

The rheumatic child is one who requires drugs on occa- 
sion. Whenever it is below par, or getting anaemic, some 
good tonic should.be administered, such as Easton's syrup, 
with which I am in the habit of combining arsenic as one of 
the most useful of remedies for cases of this sort. Five 
drops of Fowler's solution, or seven, or ten, with half a tea- 
spoonful of Easton's syrup, taken continuously for a month 



594 THE DISEASES OF CHILDREN. 

or six weeks, is a most valuable help in these cases, and 
cod-liver oil, stout, maltine, and such things, are also to be 
recommended. 

For the nervous or excitable condition, particularly in 
girls, the bromide of ammonium, bromide of potassium, 
hydrobromic acid, and manganese are of value ; and for the 
nightmare which occurs in younger children, bromide of 
potassium and hydrate of chloral combined, form almost a 
specific. Five grains of the bromide and five of chloral 
(half-drachm of the syrup), may be given to a child two 
years old, and continued as a draught at bedtime for a few 
days, with the almost certainty of success, care being at the 
same time exercised that the excitement of the day be re- 
duced to its minimum. Of the abdominal pains I have 
already spoken, and advised the administration of Dover's 
powder. Such children require attention to the bowels, 
which are liable to be irregular. If so, some gentle aperient 
in the shape of fluid magnesia, effervescing citrate, liquorice 
powder, syrup of senna, confection of senna, or the fluid ex- 
tract of cascara sagrada, in doses of ten to thirty minims, 
may be given, and a little tincture of nux vomica also is 
sometimes of advantage. The treatment of nocturnal in- 
continence is discussed in " Genito-urinary Diseases," page 
452. 



HEART DISEASE. 595 



CHAPTER XLIV. 

HEART DISEASE. 

In studying diseases of the heart in children, it is neces- 
sary to be aware of a few preliminaries. The heart's action 
is more rapid than in adults. It is not necessary to burden 
the memory with the precise data for particular periods, but 
it will suffice to remember that at birth it is about a hun- 
dred per minute, for the first two years it quickens up to one 
hundred and fifteen or one hundred and twenty, and that 
subsequently it gradually slows again. From two to six it 
remains about a hundred, and then gradually drops to 
seventy or eighty. In early childhood there is a good deal 
of difference — often as much as twenty beats per minute — 
between sleeping and waking ; the heart, of course, beating 
slow in sleep. This is naturally a matter of great impor- 
tance in disease, for if the heart's action can be thus reduced, 
as much sleep as possible will certainly be advisable in cases 
in which the heart is diseased, and needs all the rest that 
can be obtained for it. This difference is said only to apply 
to young children. One cannot, however, dogmatize on 
this matter, for it would appear, from some observations 
made for me by Dr. Newnham at the Evelina Hospital, that 
the amount of slowing is subject to some variability. In 
several cases it was noticed to be three or four beats quicker 
during sleep; although on the whole there was a well- 
marked reduction of four or six beats, and sometimes as 
much as thirty beats per minute ; and this not confined by 
any means to the youngest children, but to those of seven, 
eight, and nine years. The heart's action is also less regu- 



f:5 THE DISEASES OF CHILDREN. 

lar in its rhythm — one beat will t the next strong, 

and so on. The point of this is chiefly igs and Pepper 

Gpmark, that t be exercised in drawing conclu- 

sions in cases Q> doubtful meningitis, in which disease an 
irregular pulse is one of the most valuable diagnostic indi- 
cations. The heart's actic :; ; )ften more diffused upon the 
surface and visible than in adults ; the position and the im- 
pulse with regard to the nipple is more variable, and the im- 
pulse is Dften higher than normal in the fourth interspace. 
The precordial dulness is a little larger. Perhaps this would 
not be so in children of absolutely healthy -:::.::dard ; but so 
many suffer from moderal tortions, from bygone 

all, that the lung which should 
cover the heart more thoroughly is less expanded than natu- 
ral. The heart sounds are usually more tic-tac — that is, 
less si an in adults; althougl - an adequate 

cause — acute Bright's _-. for example — they will be- 

come thick and laboring as in an adult. This is well worth 
notice, for I have often had my attention called to the 
existence of albuminuria by the peculiar lengthening and 
laboring of the first sound. This is perhaps the 

: striking when one has to contess — at least, I should 
— that any corresponding changes in the pulse can but 
seldom be shown to exist. It is very difficult, indeed, to 
gain reliable information as regards volume and force, and 
the sphygmograph I have met with ut disappoint- 

ment in children. 

There is rhildhood in dis- 

: of the heart, excepting, of cour- ":rms 

of congenital disease : but there are one or two points which 
are worth remark, and even where the rs follow the 

same line of adults, the o of origin of 

many cases in grown-; le makes the various forms of 

heart disease in early life of considerable etiological value. 



HEART I : - 

Steiner makes the statement that a useful rule in diag- 

- is to consider all heart affections occurring under four 
s of age of congenital origin, and that only after that 

age do the acquired di ake their appearance, because 

their chief exciting cause, rheumatism, is seldom met with 
in children under four years of age. But this rule mu5t 
not be insisted upon too rigidly. Heart disease is, no 
doubt, much more common over four than under; but those 

- which occur in younger children must not be too 
hastily assumed to be of congenital origin, if by congenital 

nean such conditions as are due to malformation rather 
than to disease. Taking my own cases, the figures stand 
thus: 

Rheun:?.::: heart disease, . . . 134 cases. 

Non-rheumatic, or with no history. . 5 5 



The heart disease of chore?, r 
no doubt, seldom occurs befor 

a;re is r.zzti in : 5; :?.se = ::":hes 



: . - i 
"_ z itz 


: 


- 


: 


: 


- 


: 


; 


: : 


n 


: ; 


: : 




: : z 


- 


? 


: : 


-; 


12 


:f 


-- 


:: 


:: 


II 


- 


11 : : ' : 



Sixteen cases, therefore, occurred under four years of age. 
Of these, twelve, or three-fourths, it is true, are headed as 
congenital ; but of the twelve cases so-called, five were asso- 
ciated with a simple systolic bruit, which, in an adult, would 
certainly have been attributed either to mitral or tricuspid 
regurgitation ; and no doubt we are too apt to conclude 
that when cardiac murmurs are present in infancy, there is 
some malformation of the heart. The following case may 
point this remark : 

A male child, aet. two months, was admitted into the 
Evelina Hospital for cough and stomatitis. It was illegiti- 



598 THE DISEASES OF CHILDREN. 

mate, brought by a woman in charge, who stated that it had 
been ill three weeks. It was in a moribund state, and very 
thin. Temperature io; c . Respiration and pulse not to be 
counted. There was a loud systolic bruit heard at the 
apex and all over the right side of the chest. It died in a 
convulsion within a short time of its admission. At the in- 
spection, the mitral edge was thick, and on its surface were 
abundant inflammatory granulations, uniformly distributed 
round the orifice, and quite sufficient to interfere with its 
efficient closure. 

I could give notes of several other cases of infants but a 
few months old in whom the physical signs were in favor 
of simple mitral regurgitation. I may also add that Mr. 
Bland Sutton, in a recent paper read before the Royal 
Medico-Chirurgical Society upon the value of the systematic 
examination of still-born children, has published a case of 
recent endocarditis in an eight months' foetus, the pulmo- 
nary and aortic valves showing soft vegetations, and the 
mitral being much puckered. This distinction between 
disease and malformation, though not always practicable, is 
clearly an important one. 

Causes. — Of two hundred and forty-eight cases of heart 
disease in early life which have passed under my notice, 
either at Guy's Hospital or the Evelina Hospital for Chil- 
dren, twenty occurred in the course of acute rheumatism ; 
one hundred and thirty-four are set down as rheumatic 
(occurring, that is to say, either as the sequel of actual rheu- 
matism, or in families with rheumatic history); fifty-nine 
gave a history of chorea, or were actually choreic, at the 
time they were under treatment ; and fifty-five could not be 
attributed to any definite cause, if we except s^vcn, or, at 
most, twelve, which may have been congenital. 

As regards causes of valvular disease other than rheuma- 
tism and chorea, of which there must surely be very many, 



HEART DISEASE. 



599 



though no one at all approaches either of these in impor- 
tance, scarlatina probably comes first ; but other exanthems 
occasionally lead to endocarditis, and diphtheria, pneumonia, 
pleurisy, typhoid fever, syphilis, and pyaemia are all occa- 
sionally to be found in its company. 

It is, moreover, interesting to note how valvular disease is 
more common in females than in males all along the line, 
not only in the rheumatic and choreic cases, but also in 
others : 





Females. 


Males. 


Total. 


After rheumatism, 


. 8 9 . . 


- 45 - • 


• 134 


Choreic, 


• 45 • • 


. 14 . . 


• 59 


Other, . 


33 ' - 


. 22 . . 


55 



167 



81 



248 



Next, as to the nature of the valvular disease : 



Rheumatic, 

Mitral, . . 79 

Aortic, . . 3 

Aortic and mitral, 8 

Doubtful, . . 44 

Congenital, . . — 

134 



Choreic. 

39 

7 
11 

2 



59 



Non- 
rheumatic 
29 

I 

3 

10 
12 



Total. 

147 
II 
22 

56 

12 

248 



This table shows how large a proportion mitral disease 
bears to other forms. Eleven cases only out of the total 
were simple aortic disease, twenty-two others had both 
aortic and mitral disease. Doubtful cases form a large group. 
This heading is not intended to indicate that the existence 
of disease was doubtful, but only that its exact nature was 
not to be precisely determined. Under it are classed all cases 
of thick sounds, thumping action, displaced heaving impulse, 
in some of which no doubt the mitral was at fault, and in 
others I have suspected an adherent pericardium. But I 
do not doubt that if mitral disease had its due, many of this 



600 THE DISEASES OF CHILDREN. 

group would fall to its share ; and this would raise the pro- 
portion which mitral disease bears, so overwhelmingly, as to 
reduce all other forms to a numerical insignificance. If, next, 
we inquire further into the form of mitral disease, in five 
cases a pre-systolic bruit existed, and ten others probably 
had a contracted mitral, whilst doubtful cases are included 
in the group devoted to them. Therefore, not only can 
it be said that mitral disease is the common form of heart 
disease in childhood, but that mitral incompetence, or 
mitral regurgitation, is by far the commonest form of mitral 
disease. I lay stress upon this, because it is said and taught 
that there are two different forms of mitral contraction, and 
one of them is of congenital origin. If so, it should show 
itself in childhood ; whereas, in very young children, mitral 
stenosis is almost unknown, whether we look for it at the 
bedside by auscultation or in the post-mortem room. I have 
long been looking for such a specimen in children under five 
years of age, and have never yet seen one. Mitral regurgi- 
tation is common enough, but mitral stenosis is not found 
until we come to deal with children of eight or nine years of 
age. It is not at all common at that age, but after that it 
becomes common as years advance, and, as we all know, it 
is one of the commonest affections of adult life. 

A girl of four years was in hospital from June to Novem- 
ber, 1882, with acute peri- and endo-carditis, and acute 
pleurisy, with consolidation of the base of the left lung. Her 
illness was attributed to cold caught six weeks before her 
admission, and neither personal nor family history of rheu- 
matism could be elicited. After she left the hospital no 
more was heard of her until thirteen months later she 
came in to die. There was still, as there had been when she 
left the hospital in the previous year, a loud systolic mitral 
bruit, and the impulse of the heart was inside the nipple. 
Convulsions were the immediate cause of death. 



HEART DISEASE. 6oi 

The inspection showed a large heart with an adherent 
pericardium. The mitral valve was considerably thickened, 
but the aperture admitted one finger. The aortic valves were 
thickened. 

I give this case because it is typical of the cardiac changes 
one may expect to find in young children, and of the condi- 
tions which lead to death. The pericardium was firmly ad- 
herent, and the heart large and no doubt dilated. The mitral 
valve was considerably thickened, but not yet substantially 
contracted, for it admitted one finger, which is a fair capacity 
for the heart of a child of five years old. 

Acute pericarditis occurred in twelve cases in all — in six 
associated with acute valvular changes in chorea, in six with 
acute rheumatism. In comparison, therefore, with endocar- 
ditis, it would seem to be uncommon.* But the student 
must remember that it is found in many other conditions 
than these, and, perhaps as commonly as in any, in those 
acute inflammations of bone which are not infrequent in 
childhood and adolescence, and which go by the name of 
infective osteo-myelitis. Such cases almost always suffer 
from abscesses in the heart, and, as a natural consequence, 
acute pericarditis follows, and should the patient live long 
enough, pus collects in the sac. Pericarditis may also be 
met with after scarlatina (when, perhaps, it is rheumatic) ; 
by extension of disease from the neighboring pleura ; and 
occasionally, but very rarely, though more often in children 
than in adults, with a tubercular affection of the serous 
membrane, and as a sequel of acute Bright's disease. 
Should there at any time be evidence of a large accumula- 

* I am now only dealing with my series of hospital cases. I have seen it 
more commonly than these figures indicate, but that is probably, as I have 
remarked for empyema, because outside the hospital, more than inside, the 
practice of the hospital physician lies amongst the worst cases, not those that 
are mild. 



602 THE DISEASES OF CHILDREN. 

tion of fluid in the sac, the possibility of it being purulent 
must be considered, particularly if the inflammation have 
extended from a left-sided empyema, or be secondary to the 
existence of tubercle. A septic form oi pericarditis is de- 
scribed by most authors as occurring in the new-born infant, 
and originating in the umbilical sore. 

Acute peri- and endo -carditis are noteworthy in children 
as more liable than in adults to lead to a rapidly fatal termi- 
nation. Whether the inflammation is more severe in child- 
hood may perhaps be doubtful ; but at any rate the heart 
swells more quickly, its cavities dilate more readily, and a 
very few days' illness may determine a fatal issue. I once 
had a case of a young man, above the age, it is true, with 
which we are now concerned, who, to all appearance, had 
a healthy heart four weeks before his death. He was seized 
with acute pericarditis, and at the post-mortem the heart 
weighed 19 ounces. This looked at first like acute hyper- 
trophy, and no doubt in part it was ; but subsequent experi- 
ence has made me think that the criticism of Dr. Coupland, 
made at the time the case was recorded, was a just one, and 
that, as he suggested, something of the nature of acute 
swelling had taken place. In children an acute inflamma- 
tion of the heart of this kind takes place — pericardium, 
muscle, and endocardium, all are involved — the heart 
swells, rapidh' enlarges, and the ventricular cavities dilate, 
and then there follows that contracted leaden consolidation 
of the bases of the lungs, a condition very common in chil- 
dren, which is neither simple collapse, nor simple oedema, 
nor simple pneumonia, but probably something of all these, 
and which is an excessively anxious and dangerous condi- 
tion, because it is an indication of a sorely stricken heart. 

The physical signs in such a case are not without interest. 
The heart's action is generally of great rapidity, the anterior 
wall of the chest will enlarge rapidly in the praecordial 



HEART DISEASE. 603 

region — protruding, in fact, before an enlarged heart — the 
pulmonary second sound will be loud, and the systolic 
sound at the apex will be replaced by a confused roar. 
Should there happen to be much effusion, the conditions 
will necessarily be modified thereby, and there will be in- 
crease of the precordial dulness, particularly upwards and 
to the right, and the impulse will become less violent and 
less diffused. It is but seldom that pericardial effusion 
causes either impulse or friction sounds to disappear al- 
together. 

But there is another form of heart affection than those I 
have mentioned, and probably one of no mean importance 
— viz., simple dilatation. Dr. West records several such in 
which no disease of the valves was found post mortem. I 
have myself seen it repeatedly ; more especially, however, 
in connection with post-scarlatinal nephritis. I do not, 
however, suppose that this is the sole cause of the condition. 
On the contrary, when we consider how liable the cardiac 
muscle is to suffer in its nutrition in prolonged anaemia — a 
common affection in children — how it has been shown to 
undergo dilatation, independently of nephritis, after scarla- 
tina, measles, typhoid fever, and septic conditions of all sorts 
— nay, how it has been many a time seen that after acute 
rheumatism the only change discoverable in the heart may 
be a simple dilatation of the left ventricle — we must always 
be alive to the possibility of the existence of this condition, 
and take it into consideration in endeavoring to unravel 
the nature of individual cases of mitral incompetence. As 
I have already said, the heart probably dilates in childhood 
with undue readiness. It is this which constitutes the fatal 
element in so many cases of acute heart disease, and yet, if 
on the watch to avert it, and prompt to recognize it on its 
first occurrence, no doubt much may be done towards saving 
life, and sometimes towards restoring a heart to a normal 



6C4 THE DISEASES :? CHILDREN. 

condition,* which, were it not for this, would pass on into 
incurable disease. 

As regards symptoms, or the course of the disease, chil- 
dren are peculiar in one or tw :h are worth 
noting. They emaciate more than is customary with adults, 
and the younger the child the more markedly is this the 
case. Id very young children, the extreme emaciation and 
pallor of simple mitral regurgitation would often suggest a 
pulmonar rather than a cardiac affection, until a :scultation 
reveals the true condition; and I think it may be said, 
further, that physical examination reveals no other evidence 
of the cardiac affecti : the murmur, disturbed cardiac 
action, and increased precordial dulness. In young chil- 
dren, there is liable to be an absence of the hepatic enlarge- 

: which is common even in children a : rs older — 

of seven, eight, or nine years. Heart disease in very young 
children — of one, two, or three years old — is a wasting dis- 
ease. The reason for this is probably not far to seek: the 
cardiac defect at this time of life leads to impaired nutrition, 
as it does at any time ; but no :al, and rapid was 

results. The wasting so reduces the total blood supply 
that the circulation keeps within bounds, so to speak, and 
the mitral incompetence does not therefore produce those 

.me congestions of liver, spleen, and k hich are 

the common features of a later age. For a similar reason, 
probably, severe cardiac dro not common in older 

children. We see a child with all the local evidence of an 
enormous heart and with a large pulsating liver, perhaps 
without any ascites and generally without much anasarca, but 
such are always pale and always thin. I ?rhaps it is owing 
to some explanation of this kind that chronic heart disease 
of children is in many cases amenable to treatment, as regards 
relief to urgent ymptoms. The blood stream, diminishing, 
s, in proportion :: the emaciation, 



HEART DISEASE. 605 

dammed back irremediably in the lungs, and a temporary 
rest, with tonic and aperient medicine and careful feeding, 
certainly enables many a case of permanent mitral disease 
to go on for years.* It is difficult to prove, but I have 
thought, after watching many of these cases for a long time, 
that here is the source of part of the number of cases of 
mitral stenosis that one meets with in adolescents and adults. 
May not the mitral regurgitation of infancy and early child- 
hood, when recognized and carefully tended, be kept going 
until, in the natural order of things, the mitral inflammation 
— which at its outset produced incompetence — contracts, 
and cicatrizes, so to speak, culminating in a cure in one 
sense — viz., a contraction of the orifice ? The natural ten- 
dency of all inflammatory conditions of the mitral valve is 
towards constriction of the valve, but, like its parallel, 
urethral stricture, in the presence of an active dilating force 
— in the one case in the passage of urine, in the other, of 
blood by muscular propulsion — years pass by before any 
serious amount of disease is produced. 

As regards the symptoms of both endocarditis and peri- 
carditis, it must further be said, that in children of any age 
they are liable to be very obscure. A short, dry cough, 
breathlessness on exertion, and palpitation, may be all that 
have been noticed, combined with a gradual loss of flesh. 
But when examined, there may be the rounded chest, the 
increased prsecordial dulness, the displaced, diffused, and 
heaving impulse, the roaring systolic bruit, which betoken 
not only old valvular disease but consecutive hypertrophy 
and dilatation also. 

Prognosis. — Acute peri- and endo-carditis, if they be 
attended with much turbulence and rapidity of action of the 
heart, or any evidence of consolidation of the lungs, require 

* West gives several cases of the kind, and refers to a passage in Dr. 
Latham's book of similar purport. 

51 



606 THE DISEASES OF CHILDREN. 

a guarded prognosis, based upon a careful study of the child 
and its surroundings. If, with the conditions just men- 
tioned, the child be restless, unable to lie down, takes food 
badly, sleeps badly, and, above all, vomits, the condition is 
one of great danger. At the same time, it is hardly possi- 
ble to avoid mistakes in forecasting the issue, seeing that 
some very bad cases rapidly improve, the consolidation of 
the lung and pleuritic effusion clearing up, and the heart's 
action quieting down ; while others no worse, perhaps not 
so bad as they, die off either quickly, or perhaps after 
hovering for some days without improvement. 

In chronic valvular disease, the opinion must be based 
upon the progress of the case. If the child takes food well, 
and the heart's action becomes quieter, the impulse less 
diffused, the separate sounds more distinct, and the con- 
gested viscera less hampered, whilst it is able to take the 
recumbent posture when asleep at night, further hopes may 
be entertained that it will ultimately reach a safe position — 
" safe but not sound," as Latham expresses it. 

In simple dilatation, the prognosis must also depend upon 
the extent of the dilatation and the evidence of impaired func- 
tion which may be present. With close watching, the strictest 
rest, and the careful administration of digitalis and such 
like remedies, some of these cases unquestionably recover. 

The treatment presents no special features in children, 
but one may again insist that in acute cases dilatation of 
the heart takes place with readiness, and this we must be 
on the watch to prevent or remedy. Opium is one of the 
most valuable remedies for this purpose, and with children 
of this age, six to fourteen, it may be used freely — three or 
four grains of Dover's powder every four hours may be 
given. Belladonna is useful, combined with bromide or 
iodide of potassium, according as there is need for soothing 
turbulent action, or for procuring the absorption of inflam- 



HEART DISEASE. 60J 

matory products. Then comes digitalis or the convallaria 
majalis, the former being much the more reliable in its 
action ; and last, but not least, I shall mention stimulants, 
which are very necessary in some of these cases. A child 
often may have three or four ounces of wine a day, if by 
careful watching the conditions seem to improve under its 
use. If there be much pericarditis, counter-irritation to the 
praecordia may be kept up by a mustard-leaf or lin. iodi,* 
and the chest wrapped round in a cotton-wool jacket. 
Absolute rest must be enforced for a long time, and, in the 
convalescing stage, iron and quinine should be administered 
for some weeks. 

Absolute rest must be continued for a long time. It may be 
well to emphasize this. There is no more important rule 
of practice, and none that is more often neglected. The 
case has been one of acute peri- and endo-carditis, and the 
heart is smothered in a thick jacket of lymph, its muscular 
wall is swollen and degenerated, its cavity in all probability 
dilated. The subject is a child of ten or twelve years of 
age. Is a two or three months' recumbency longer than is 
necessary under such circumstances for the repair of so 
damaged an organ ? Is it too much to insist upon, when 
the future of a just-opening life depends upon it? The 
surgeon with the diseased joint makes light of a year of 
rest; yet who has not seen a child after acute pericarditis 
skipping about at the end of a month or six weeks as if 
nothing had been amiss ? This ought not to be ; and in all 
cases, after rheumatic peri- and endo-carditis, the heart is 
to be rested in all possible ways for several months. There 

* Linimentum Iodi, Br. P., contains : 

Iodine, . . . . . • X X ounce 

Iodide of potassium, . . . y z " 

Camphor, . . . . . . j£ " 

Rectified spirit, 10 fluid ounces. — Ed. 



608 THE DISEASES OF CHILDREN. 

are many ways of accomplishing this ; but chief of all, natu- 
rally, is the avoidance of all bodily exertion. Where it is 
possible, no walking, not even feet to the ground, should 
be allowed for three months. The child is to be carried 
everywhere ; and when at last it is allowed to walk about, 
the pulse and heart's action should be carefully watched. 
We may remember, too, that the heart is rested also by 
sleep. I have already remarked that the beats of the heart 
are sometimes considerably reduced in number at this time. 
It may be rested also by diet and general attention to 
bowels, etc. The food must never be allowed to overload 
the stomach, or stimulate the circulation too much. Rest 
is also to be obtained by tonics, which help the cardiac 
muscle to contract and slow the action of the heart. Here 
it is that iron acts — it restores the nutrition of the muscle, 
and thus slows the action. Digitalis, acting in another 
way, accomplishes the same purpose, and allows the heart 
more rest by prolonging the pause. Belladonna, convallaria, 
bromide of potassium, and hydrobromic acid are all use- 
ful, either in the same way or as sedatives in quieting the 
excessive action of the heart. 

Finally, as regards pericarditis, although purulent peri- 
carditis is by no means common, nevertheless, the student 
must remember that all serous inflammations in childhood 
have a greater tendency to the formation of pus than in 
adults. Therefore, supposing that in a case of pericarditis 
there is evidence of much effusion, and that evidence re- 
mains persistent — and still more so if the effusion has come 
on insidiously without any well-marked pericardial rub — 
the pericardial sac may possibly contain pus, and should it 
do so, the question of its removal ought to be discussed. 
In such cases the child is very anaemic and very ill, and 
any treatment is only too likely to be ineffectual to avert a 
fatal result. Nevertheless, what little evidence there is 



HEART DISEASE. ,609 

points in favor of an exploration by a fine syringe, and, if 
pus should be found, of a free incision. Cases of this sort 
are no doubt very rare, and they usually pass away undiag- 
nosed (but this need not be). 

[Paracentesis of the Pericardium. — Whenever an effusion 
into the pericardium, whether it be serum, pus, or blood, 
accumulates so rapidly or in such quantity that it threatens 
life, or where it refuses to undergo absorption by ordinary 
treatment, it is the duty of the attendant to tap the dis- 
tended sac. This rule holds good even though there be 
such constitutional disease present as must, in all probability, 
soon bring about a fatal termination. 

Aspiration is the method preferred to all others. It does 
away with the danger of suppuration, of hemorrhage from 
the wounding of an artery, and of fluid dribbling into the 
pleural sac, should it be punctured. The entire amount of the 
fluid can be withdrawn, and little injury will be done should 
the fine needle pass through the edge of the lung or strike the 
ventricular wall itself. Fitch's trocar, attached to Potain's 
aspirator with a vacuum-jar should be used, the stopcock 
being turned to allow the atmospheric pressure to exert its 
force as soon as the trocar is buried beneath the integument. 
The operator is thus at once apprised of its entrance into 
the collection of fluid. 

The point of puncture preferred is the fifth intercostal 
space, close to and above the junction of the sixth rib with 
the corresponding cartilage. If there be evidence of point- 
ing, the tapping should be done at the most prominent 
point. Should the heart sounds be very loud at the point 
advocated for tapping, and adhesions be inferred, some other 
spot must be selected. In a monograph entitled " Para- 
centesis of the Pericardium," by John B. Roberts, M.D., 
from which this extract is taken, a table of sixty cases is 
given. Of these there were twenty-four recoveries and thirty- 



6lO THE DISEASES OF CHILDREN. 

six deaths. Of those in the death column who survived 
the operation by a day, the average length of life was twenty- 
seven days. In other words, in those not already moribund, 
and who survived the shock of the operation, there was a 
probable prolongation of life of nearly four weeks.] 

Malformations. — There are many varieties of malfor- 
mation of the heart, or, as it is generally called, congenital 
disease. There is patency of the foramen ovale, patency 
of the ductus arteriosus, deficiency of the septum of the 
ventricles, and stenosis of the aorta where the ductus arte- 
riosus opens into it, just beyond the left subclavian artery. 
There are other anomalies, such as a single ventricle and 
auricle, one ventricle to the two auricles, or the viscera are 
transposed, the heart being placed on the right side of the 
chest and the liver and spleen transposing in correspondence, 
and lastly there are the various forms of adhesion and steno- 
sis of the various valvular orifices, chiefly of the pulmonary 
artery and of the aorta, and occasionally of the tricuspid 
and mitral also. But to give such a list as this is only to 
name the chief conditions. It will be quite unnecessary, 
however, to describe all these seriatim. Those malfor- 
mations consisting of reduction in the number of the 
cavities, are very rare, and generally destroy life quickly ; 
the only one, practically, which is in any way common — 
and this, of course, not so in the sense that its occurrence 
bears any proportion to that of other diseases of the heart — 
is stenosis of the pulmonary artery, with which is usually 
combined a deficient septum between the ventricles. Next 
after these in frequency comes a patent foramen ovale and 
patent ductus arteriosus. And all these, while they may, 
and frequently do, occur independently, more often are 
found in company. 

Malformations of the heart vary as, and are in great mea- 
sure to be explained by a knowledge of, the stages of devel- 



HEART DISEASE. 6ll 

opment of the foetal circulation. In the earliest embryonic 
days the heart has no separate cavities ; it subsequently 
divides into two, and later into the four of the mature foetus. 
So with malformations ; do they occur early, we meet with 
one auricle and ventricle, the pulmonary and systemic ves- 
sels coming off from the ventricle in common. A little later, 
and there is the heart of three cavities, two auricles, and a 
ventricle. Gradually, as the imperfections of later develop- 
ment remain persistent, so there is found a heart with four 
cavities more or less complete, usually with some deficiency 
in the septum, if not of the auricle, still of the ventricle. 
Now it is that the main vessels go wrong; the pulmonary 
artery fails to develop, or its valves form a perforated cupola, 
or the conus arteriosus becomes contracted ; the blood under 
these circumstances cannot pass easily to the ductus arte- 
riosus by means of the pulmonary artery, and the more ready 
route, by the interventricular septum, is kept open, the pul- 
monary artery contracts, and the aorta becomes twisted 
towards the right ventricle. This is by far the commonest 
malformation — the pulmonary artery contracted, the inter- 
ventricular septum open, and the aorta, arising, as it is said, 
either from the right ventricle or from both — and it is at 
once apparent why it should be so common ; for, in addi- 
tion to the complex process which necessarily takes place 
in the accurate adjustment of the valves and in the forma- 
tion of the vessels from the branchial arches, it is brought 
about by other conditions which interfere with the natural 
flow of the circulation at that time of life. For example, 
a premature closure of the ductus arteriosus will so ob- 
struct the circulation along the pulmonary artery, that the 
blood will tend, as in the contractions at the ostium, to 
find a more ready outlet by means of a still imperfect 
septum. The premature closure or permanent patency of 
the foramen ovale or ductus arteriosus are usually amongst 



6l2 THE DISEASES OF CHILDREN. 

the malformations occurring during the later periods of 
foetal life. These are, perhaps, less easy of explanation — 
the former particularly so. Of permanent patency it may 
be said, in the words of the late Dr. Peacock, whose mas- 
terly thoroughness has well-nigh exhausted his subject, 
" Under all circumstances, it is very generally associated 
with some obstruction at or near the pulmonic orifice. " 

To make the subject, however-, more clear, let us with Pea- 
cock turn it round and trace the conditions of the heart from 
the more perfect to the rudimentary forms. He says :* 

" If, during foetal life, after the septum of the ventricles has 
been completely formed, the pulmonic orifice should become 
the seat of disease, rendering it incapable of transmitting the 
increased current of blood required to circulate through the 
lungs after birth, the foramen ovale may be prevented clos- 
ing; and, if the obstruction take place at an earlier period, 
when the septum cordis is incomplete, a communication may 
be maintained between the two ventricles. The same cause 
may also determine the permanent patency of the ductus 
arteriosus; for if, during foetal life, the pulmonary artery be 
much contracted or wholly obliterated, the blood must be 
transmitted to the lungs through the aorta; and, unless the 
ductus arteriosus be itself obstructed, that vessel will neces- 
sarily become the channel by which it is conveyed. Similar 
effects would result from obstruction in the course of the 
pulmonary artery or in the lungs, in the right ventricle, or 
at the right auriculo-ventricular aperture. So also, obstruc- 
tion at the left side of the heart, as at the left auriculo-ven- 
tricular aperture, or at the orifice or upper part of the aorta, 
would cause the current of blood to flow from the left auricle 
or ventricle into the right cavities, and thence, through the 
pulmonary artery and ductus arteriosus, into the aorta, and 

* On Malformation of the Human Heart, pp. 159-60. 



HEART DISEASE. 613 

would equally determine the persistence of the foramen and 
duct or of an opening in the ventricular septum. The pul- 
monary artery and aorta would indeed appear to be either 
capable of maintaining for a time both the pulmonic and sys- 
temic circulations ; and the necessary effect of the one vessel 
having the twofold function to perform would be to give rise 
to hypertrophy and dilatation of the cavities of the heart 
more directly connected with it, and to the atrophy and 
contraction of those which are thrown out of the course of 
the circulation. 

" These effects of obstruction at the different apertures 
must vary, according to the period of foetal life at which the 
impediment occurs. If the pulmonary artery be obstructed 
before the complete division of the ventricles, the aorta may 
be connected with the right ventricle, and both the systemic 
and pulmonic circulation may be chiefly maintained by that 
cavity. If, on the other hand, the obstruction take place 
after the completion of the septum, the double circulation 
will be carried on by the left ventricle :— in the former case 
the left ventricle, in the latter the right, becoming atrophied. 
The degree of obstruction may also influence the course of 
the circulation, and so affect the development of the heart. 
A slight impediment at or near the pulmonic orifice, while 
the growth of the septum cordis is in progress, will proba- 
bly give rise to hypertrophy and dilatation of the right ven- 
tricle, and to the persistence of a small inter-ventricular 
communication. More aggravated obstruction, on the con- 
trary, may arrest the progress of development, and throw 
the maintenance of the circulation on the left ventricle. The 
influence of obstruction at or near the pulmonic orifice or in 
some other portion of the heart, in modifying or arresting 
the development of the organ, is thus far capable of demon- 
stration ; but it is probable that similar causes may equally 
give rise to the more extreme degrees of malformation, in 

52 



6 14 THE DISEASES OF CHILDREN. 

which one or other cavity retains its primitive undivided 
condition. For if obstruction taking place during the growth 
of the septum be capable of preventing its complete develop- 
ment, it may be inferred that impediments occurring at a 
still earlier period may entirely arrest the formation of the 
septa, so as to cause the ventricle, or auricle, or both, to re- 
main single, or to present only very rudimentary partitions. 
It cannot, indeed, be disputed that in some cases, more par- 
ticularly when the arrest of development is extreme, no 
source of obstruction exists to which the defect can be as- 
signed ; but it must be borne in mind that the absence of 
any obvious impediment to the circulation, after a lapse of 
a considerable period, as in persons dying several years after 
birth, does not afford any proof that some obstruction may 
not have existed when the deviation from the natural con- 
formation first commenced. On the contrary, as remarked 
by Dr. Chevers, the condition which at first sight appears 
least in accordance with the theory of obstruction — that in 
which the pulmonary orifice and artery are dilated — really 
affords evidence that some serious impediment must have 
existed in the lungs or elsewhere, though it may have en- 
tirely disappeared." 

There are yet other malformations to be considered, not, 
however, of so much importance as diseases incidental to 
childhood, as for the questions they raise as regards the eti- 
ology of valvular disease, and I shall, therefore, only mention 
them to awaken interest and watchfulness for their detection. 
The first and more important is slight congenital defect in 
the various valves, which, by making them work at a disad- 
vantage, or inefficiently under increased strain, becomes an 
important source of disease in later life. Peacock was a 
strenuous advocate for disease having this origin, and his 
reasoning was based upon a very full inquiry into the facts 
for himself, and a perusal of published cases. There is no 



HEART DISEASE. 615 

doubt much to be said in its favor. Some intra-uterine en- 
docarditis occurs, and slightly thickens one or other of the 
valves. Adhesion between the flaps or cusps is thus pro- 
duced, and in the ordinary course of wear and tear such 
defects become subsequently accentuated, and disease 
gradually progresses as the subject advances in years. 
There can be no doubt of the occasional existence of mal- 
formations, which, though slight, are sufficient to lay the 
train of permanent disease, and to this extent it must be 
allowed that an argument exists for the occasional occur- 
rence of mitral stenosis of a congenital form. At the same 
time, it must be said that on the left side this condition is 
very uncommon, and on either side, in proportion as 
changes — other than the perfect fusion of the valves, chiefly 
of the pulmonary and aortic valves, in a dome-shaped cu- 
pola, which all allow to be of congenital origin — are called 
congenital, so it becomes difficult to be positive concerning 
the time at which they occur, mainly because a careful ex- 
amination of acquired valvular disease, rheumatic and other, 
aortic or mitral, shows that adhesion of the valves, matting, 
and the more moderate degrees of fusion, can be traced in 
all stages as the result of endocarditis of extra-uterine life. 
So much, indeed, is this the case, that it is very difficult to 
say what is certainly congenital. Nevertheless, the student 
should bear this question in mind, and endeavor, not only to 
satisfy himself on the matter, but, if possible, elucidate it by 
careful examination of such cases as endocarditis in very 
early life as come before him. 

I can only allude to one other condition — viz., the con- 
traction of the aorta beyond the left subclavian artery. The 
aorta at this spot is more or less constricted, as if a string 
had been tied around it. Sometimes it is completely oblit- 
erated at this spot. The ductus arteriosus is sometimes 
patent. The chief interest of the condition lies in bearing it 



6l6 THE DISEASES OF CHILDREN. 

in remembrance and correctly diagnosing it. It is compat- 
ible with many years of existence. In the two cases which 
have come under my own notice, one was a man, aged 
twenty-seven, the other, a man of thirty-seven years. It 
almost necessarily leads to hypertrophy of the left heart, and 
very probably to dilatation also ; while, from the fact that 
the circulation has to be carried to the lower part of the 
trunk by the subclavian and other vessels at the root of the 
neck, the enlargement of the surface vessels may allow it to 
be recognized. I believe that I have once recognized it in 
this way in the case of a man in whom, with obscure cardiac 
symptoms, some large arteries could be traced coursing be- 
neath the skin in the scapular region. 

Symptoms. — The general symptoms of malformation of 
the heart are cyanosis, palpitation, and more or less impedi- 
ment to the respiration ; and they are generally present from 
birth onwards. But they may be altogether absent ; they 
may occur only in paroxysms, or they may be absent for 
some time, even years, and come on without any assignable 
reason as the child grows older. Such children, are, how- 
ever, usually ailing from birth; they are easily chilled, and 
subject to attacks of bronchitis. 

As regards the local symptoms, bruits, etc., by which the 
particular malformation may be recognized, it can hardly be 
said that any are diagnostic. There may be no murmur 
even though the cyanosis is extreme, and when a bruit does 
exist, it is often so loud and harsh over the entire praecordia, 
that it is a matter of the greatest difficulty to localize it de- 
finitely. In looking over fourteen cases of which I have 
notes, I find that two are cases of transposition of the heart; 
one of the heart only; a second of the heart and viscera. 
In both these a systolic bruit existed in the praecordial re- 
gion, and to the right side, which is not unlikely to have 
been developed in connection with disease of the pulmonary 



HEART DISEASE. 617 

artery. In five others the bruit was pulmonary or septal in 
position. In five there was an apex bruit, one accompanied 
by a thrill, and in which it was hardly possible to arrive at 
any positive conclusion ; in one, with much cyanosis and 
disturbed action, there was no bruit at all. In one there 
was a persistent humming-top bruit, which suggested a 
patent ductus arteriosus ; and in one a loud systolic bruit, 
to the right of the spine more particularly, the nature of 
which was uncertain. 

The chief point to remember is that the larger proportion 
of cases by far are contracted conditions of the pulmonary 
artery, combined with a patent septum ventriculorum ; and, 
consequently, whatever the variations which the prsecordial 
bruit may present, unless other indications allow of its ex- 
clusion, this malformation is in all probability present. Its 
proper characteristics, however, are a systolic bruit along the 
left border of the sternum from third to fifth rib; most in- 
tense in the mammary line, and running upwards to the left 
clavicle, but not along the aorta or towards the axilla. There 
may sometimes be a thrill over some part of the area occu- 
pied by the bruit. The prsecordial dulness is usually ex- 
tended laterally to the right, by reason of the dilatation of 
the right side. A patent foramen ovale, although occasion- 
ally associated with cyanosis without other malformation, 
has so frequently been found without symptoms of any kind, 
that it can be seldom diagnosed. 

A patent ductus arteriosus can be but rarely capable of 
recognition. Walshe, from two published cases, thinks it 
" a matter of fair conjecture, that if a cyanotic adult (for 
which in this case we must read child) presented the signs 
of hypertrophy of the right heart, a negation of murmur at 
either apex of the heart, a single prolonged diastolic, or a 
double murmur, of maximum force at the pulmonary carti- 
lage, and not conducted downwards, the cause of these com- 



6l8 THE DISEASES OF CHILDREN. 

bined conditions would be found in a patent state of the 
ductus arteriosus/' I venture to doubt even so cautious a 
conclusion as this, because, from a case which has lately- 
been under my observation, it is certain that a dilated pul- 
monary artery is by itself a sufficient cause of a bruit of this 
kind ; and both in Dr. Fagge's case, and that of Jaksch, from 
which Walshe draws his conclusion, the pulmonary artery- 
was dilated. In the particular case I refer to, and which 
came frequently under my notice, the peculiarity of the bruit 
(it was delayed systolic rather than diastolic, although it 
continued on beyond the systole into the diastole) consisted 
in its time and in a peculiar musical tone, and I went so far 
as to discuss not only the question of a patent ductus but 
also that of a communication between the aorta and pul- 
monary artery, as the result of aneurism, and also of simple 
aortic aneurism. All of these seemed possible. A mere 
dilatation of the pulmonary artery had not occurred to me, 
but such the post-mortem proved the condition to be. 

Now this may at first sight appear to be beside the ques- 
tion of congenital disease, because it is hardly a point which 
concerns the diseases of childhood ; a patent ductus being a 
recognized condition, a simple dilatation of the pulmonary- 
artery hardly so. But a little reflection will convince one 
that this view is a narrow one. It has always been a ques- 
tion of interest to those who have made a study of the dis- 
eases of the heart and lungs how far collapse of the lungs in 
early infancy and childhood may be conducive to actual dis- 
ease, and it is obvious that in atelectasis there is a sufficient 
cause, not only of dilatation of the pulmonary artery, but of 
patency of the ductus, dilatation of the right side of the heart, 
and patency of the foramen ovale, did it but occur a little 
prior to the time at which closure takes place in these aper- 
tures of communication between the two sides of the heart. 
We have, however, in atelectasis a cause of chronic valvular 



HEART DISEASE. 619 

disease, if not of actual malformation, on the right side, 
which is probably of far more importance than that usually- 
ascribed to it; and for this reason the physical signs of dila- 
tation of the pulmonary artery are well worth the attention 
of the student. 

Simple stenosis of the aorta may be easily recognized by 
a loud systolic bruit along the aorta, by a systolic thrill, and 
by a slow pulse. It is not a condition which comes often 
under notice in childhood. It would appear that, if it be 
congenital, the disease goes on for a long time, the left ven- 
tricle undergoing hypertrophy, and compensation being 
complete. After a time, however, at two or three and 
twenty years of age, dilatation begins, and then it is that 
these cases come for treatment. 

Prognosis, — What is the duration of -life in these cases is 
another question, which can only be answered in the most 
general terms. As a rule, all serious malformations cut life 
short early. The slighter forms, such as slight apertures in 
the foramen ovale or in the septum, are compatible, at any 
rate, with many years of existence. The risk to life is natur- 
ally in proportion to the derangement of the circulation ; and 
according to Dr. Peacock, the commoner forms of malfor- 
mation rank in order as follows, commencing with the least 
dangerous : 

Moderate contraction of the pulmonary artery. 
Contraction of pulmonary artery and patent foramen 

ovale. 
Contraction of the pulmonary artery, with imperfect 

septum. 
Completely impervious pulmonary artery. 
A single ventricle to one or two auricles. 

While, however, all these bring life to a standstill within 
a few weeks or months in the great majority of cases, and 



620 THE DISEASES OF CHILDREN. 

those at the bottom of the list more speedily than those at 
the top, nevertheless there is no one of them which is not 
compatible with a life of many years. Therefore, for indi- 
viduals, the prognosis must be somewhat guarded. 

The causes of death are usually cerebral disturbance due 
to cyanosis, or imperfect expansion and collapse of the lungs, 
with some intercurrent bronchitis. 

Treatment. — This resolves itself into a few common- 
sense rules, which any one can suggest to himself. These 
children suffer from cold; they must, therefore, be well 
clothed, and in cold weather be kept as much as possible in 
one uniform temperature. This is the more necessary, as 
the lungs are in a permanent state of engorgement and very 
liable to bronchitis, and sudden changes of temperature 
increase the risk. An attack of bronchial catarrh in any 
case of this kind may prove the last straw which brings the 
laboring circulation to a stop. Children with congenital 
heart disease are not uncommonly subject to outbursts of 
passion ; these must be guarded against as much as possible. 
The diet must be carefully regulated down to simples in 
small quantities, at somewhat more frequent intervals than 
is the usual habit of children : and if the emaciation makes 
way, they must be fed with tonics, cod-liver oil, and mal- 
tine. 

Cyanosis. — Two views have been held as to the cause of 
the extreme lividity that is so common a feature of con- 
genital disease — one that it is due to the mixture of arterial 
and venous blood in the course of the circulation ; the other 
that it is dependent upon the congestion which follows upon 
the obstruction of the pulmonary circulation. Of these two, 
the latter is without doubt the more generally correct, for 
these reasons chiefly, that it is not uncommon to find ex- 
treme cases of malformation with no cyanosis, or which are 
cyanotic only in paroxysms ; and also that simple pulmo- 



HEART DISEASE. 62 I 

nary disease has been known to cause as extreme cyanosis 
as any malformation of the heart ever does, and that with- 
out any abnormal communication between the two sides of 
the heart. It is now, therefore, very usually taught that the 
cyanosis is due to the extreme obstruction in the lungs, and 
the consequent retardation of venous blood in the cutaneous 
capillaries. But this is not the whole truth, for such a dis- 
coloration as is met with from congenital heart disease is 
very uncommon from any other cause. It is therefore prob- 
able that the dilatation of the cutaneous capillaries most 
commonly reaches a sufficient pitch only when the disease 
takes effect in earliest infancy ; and it is not unlikely, also, 
that a certain thinning or delicacy of the skin is requisite to 
its full exhibition. Certain it is that, where the cyanosis is 
well marked, the skin is of a remarkably silky, almost 
greasy, softness. 

Aneurism is not a common disease in childhood; but 
when it occurs, and it may do so even in any of the larger 
vessels, such as the carotid, or iliacs, or femorals, it is almost 
always associated with (many think due to) the plugging of 
the vessel from an embolus, dislodged from the valves of 
the heart and carried to the diseased spot. The history of 
such a case is probably this : an inflammatory clot from the 
valves is dislodged and catches across the fork of a vessel, 
leads to clotting there and, then, to inflammation of the 
clots of the artery ; the artery thereupon softens and allows 
of dilatation, under the pressure of the blood behind the 
plug, and an aneurism is formed. There is some doubt 
amongst pathologists about the exact mode of production 
of the aneurism, but of the fact, and of its association with 
embolism, there is no doubt. Aneurisms of this kind have 
been found in young people on the internal carotid, axillary, 
femoral, and popliteal vessels, not to mention the cerebral 
arteries, which have often been affected ; indeed, supposing 



622 THE DISEASES OF CHILDREN. 

that a young person should die with apoplexy, death is 
probably due to such an aneurism, which has ruptured after 
its formation. Occasionally, aneurism produced in this way 
has come under surgical treatment for the cure of the dis- 
ease ; but it is well to remember that the condition is an 
indication of the existence of the worst possible form of 
disease of the valves of the heart, one usually associated 
with embolism in many of the organs, and with hectic fever. 
It is nearly always fatal within a few weeks ; and there is 
hardly scope for treatment other than palliative. 



PURPURA — HAEMOPHILIA — SCURVY — A'N/EMIA, ETC. 623 



CHAPTER XLV. 

PURPURA— HEMOPHILIA— SCURVY— AN2EMIA, ETC. 

Certain other diseases may be noticed in connection 
with the heart, though, strictly speaking, they are probably 
blood diseases rather than diseases of the circulatory sys- 
tem. 

Purpura is one of these. It is by no means uncommon 
in children of the lower classes as the result of bad feeding 
or bad living. It may be met with in all degrees, from 
scattered petechise in the skin, of small size, and which 
might easily be mistaken for fleabites, or larger and more 
profusely spread, up to considerable extravasations into the 
subcutaneous tissue, or to bleeding from the nose, gums, 
stomach, bowels, and kidney. Purpura when confined to 
the skin is sometimes called simple ; when affecting mucous 
membranes also, purpura hemorrhagica, or morbus macu- 
losus. Purpura is a condition which is found associated with 
many diseases, such as rickets, rheumatism, blood-poison- 
ing of various septic kinds, or ulcerative forms of heart 
disease, and it is produced in some subjects artificially by 
the administration of drugs, such as iodide of potassium. 
Many of these forms, however, are allocated to the distinct 
disease, and we have thus purpura rheumatica, the petechiae 
of scarlatina and small-pox, and the purpura of heart dis- 
ease. These are not generally included in the term purpura, 
but only such cases as originate, often without fever, with- 
out any more definite cause than prolonged failure in nutri- 
tion, dietetic or other. Even extreme cases of this kind are 
not uncommon, and they usually speedily get well upon 



624 THE DISEASES OF CHILDREN. 

proper diet. I have, however, met with one case which 
was associated with fever and severe intestinal lesions, which 
speedily proved fatal. The intestine was found in this case 
in a spongy, tufted condition, not unlike the gums as seen 
in bad cases of scurvy. 

Hemorrhage occasionally occurs about the fundus oculi 
in purpura. This lesion has of late been frequently de- 
scribed ; but, so far as I know, it has no special importance 
attaching to it. A girl, set. four, was admitted on July 31, 
1877. She had been languid and fretful, suffering from 
stomatitis for three days, and two days before admission the 
body became covered with purple spots. The gums com- 
menced to bleed on the morning of admission, and blood 
had also came from the right ear, from which for two years 
there had been an occasional discharge of pus. The child 
by nature was of a dark, sallow complexion, but had en- 
joyed good health. It had been noticed that since her birth 
any scratch or cut would bleed freely. The child had been 
well fed, was fond of vegetables, and had had plenty. The 
mother was of dark complexion, and believed that she had 
had a similar attack when a child. The gums were much 
swollen, greyish looking, and fungating. All parts of the 
body were covered with small petechiae but no bruises. 
The child lay feeble and exhausted, with a temperature of 
99.8°, pulse 134, respiration 20. The urine was normal. 
The thoracic and abdominal viscera also. Gallic acid, in 
six-grain doses, was administered three times daily, and 
green vegetables, milk, and beef-tea were ordered. The 
bleeding from the gums becoming serious, they were painted 
with tincture of perchloride of iron. She vomited blood 
twice only; passed none in the evacuations and none in the 
urine. The bleeding from the gums gradually ceased, and 
the spots faded from the skin, and she left the hospital well 
after about three weeks' stay. 



PURPURA — HEMOPHILIA — SCURVY — ANEMIA, ETC. 625 

During her illness the fundus oculi was examined for 
hemorrhage, and on the right side, above and internal to 
the optic disc, and at some distance from its margin, a large 
dark round blotch was seen, with a haze over it, and a white 
margin surrounding it. Near it was a large vessel. The 
appearances were those of hemorrhage into the choroid, 
with either atrophy around it or the white margin of a dis- 
placed retina. Both discs were whitish, and the chorodial 
pigment was very unevenly distributed — some parts of the 
choroid looking white by contrast with others. 

The child was seen again some months later, and, the 
pupils being dilated with atropine, the fundus was fully ex- 
amined. No trace of the former hemorrhage existed, and 
the uneven distribution of pigment so marked before was 
now hardly noticeable. 

Five cases of purpura that have been under my care in 
the Evelina Hospital have all been of the female sex. 

Of the pathology* of purpura nothing is known; the blood 
has been examined, without result ; the bloodvessels also, 
with no decided bearing. All that is known is the practical 
fact that it depends often upon deprivation of particular 
kinds of food, and quickly disappears when these are sup- 
plied. 

It is indeed but seldom fatal, although, in severe cases, 
the amount of bleeding from the nose, the bowels, or the 
kidney, may give rise to some anxiety. 

Treatment. — Rest in bed is necessary if there be any 
severity about the attack ; and to stay the bleeding some 
gallic acid may be given in honey, or some turpentine in 
syrup. The body should be kept cool, and ice may be ap- 
plied if necessary to the head or spine, or even placed in the 
rectum. Plenty of good milk should be given, and orange, 
lemon, or lime-juice, with green vegetable diet and under- 
done meat or beef juice. 



626 THE DISEASES OF CHILDREN. 

Haemophilia. — Purpura — the just detailed case in particu- 
lar — with its history of a tendency to bleed to excess on 
slight scratches, etc., leads naturally to the consideration of 
haemophilia, or the haemorrhagic diathesis. It is a disease 
which is strongly hereditary, and it is far more common in 
males than in females, the proportion being about eleven to 
one. As regards its transmission, there is this curious fact 
about it, that it passes to the males through the females, the 
mothers remaining quite healthy whilst passing on the dis- 
ease to their sons, and fathers who are bleeders but rarely 
transmitting it to their sons. The females in bleeder fami- 
lies, according to Dr. Wickham Legg, from whom I am con- 
densing this account, are, unfortunately, remarkably fertile. 

Symptoms. — The subjects of haemophilia differ in no ap- 
preciable respect from other people. They are usually 
healthy. The symptoms usually show themselves soon after 
birth, within the first year or two of life, and are character- 
ized either by bleeding from the nose or mouth or sponta- 
neous ecchymoses in the skin. In the extreme cases, found 
usually only in the males, the bleeding arises spontaneously, 
or from the most trivial causes, and occurs not only in the 
skin and from mucous surfaces, but large extravasations take 
place into the subcutaneous tissue and intermuscular septa, 
and into the cavities of the larger joints. To this escape of 
blood into the joints is due the obstinate swellings of the 
joints, particularly of the knee, which characterize this dis- 
ease. 

Of the few cases that have come under my own notice, 
one was a boy, aged four, who had persistent epistaxis after 
some slight injury. Another, a boy, aged nine, with epis- 
taxis to blanching, whose brother suffers also from frequent 
epistaxis. A third, a male, of eighteen months, I am uncer- 
tain about, from the possible existence of rickets. He had 
had convulsions, and his head was large ; but he looked in 



PURPURA — HAEMOPHILIA — SCURVY — AN/EMIA, ETC. 627 

perfect health, except that he was covered with painless 
lumps, of bruise-like appearance. In some of these the 
amount of extravasated blood was large. The whole body 
was dotted over with petechias. One sister had passed blood 
per anum, and had been in Guy's Hospital for haematuria. 
And another boy, who died aged twelve, was said also to 
have had lumps much like those of this child. A fourth, a 
boy, aged five, bled profusely after the extraction of a tooth- 
Several others in the same family had suffered from the same 
thing, and there is a married sister who always loses severely 
at her confinements, and whose catamenial flow lasts a fort- 
night out of every month. 

Pathology. — Nothing is known of the cause of this con- 
dition. The various viscera have been examined, and the 
blood also, but mostly without result. 

Diagnosis. — This is not easy from purpura due to other 
causes. Attention must be paid to the history, and also to 
the family history and to the sex of the patient. 

Prognosis. — The disease appears to be persistent through- 
out life, and there is naturally a risk to life from the occur- 
rence of profuse hemorrhage at any time. Nevertheless, if 
all due care be taken to avoid injury, the extraction of teeth, 
etc., and to keep in as good a state of health as possible, 
there is no reason why old age should not be attained. As 
regards the local affection of the joints, it is slow to depart, 
and is often associated with pain and fever. 

Treatment. — The perchloride of iron appears to be the 
best remedy, though none can be said to materially influence 
the disease. Preventive treatment is the most effective — viz., 
the avoidance of injury in any shape, warm clothes, resi- 
dence in a warm climate, and good living. When hemor- 
rhage has been so severe as to threaten life, transfusion may 
be had recourse to. The joint affection must be treated 
upon general surgical principles, by rest, splints, etc., bearing 



628 THE DISEASES OF CHILDREN. 

in mind that the fluid within is blood, and therefore that, 
after the inflammation has subsided, gentle movement of the 
joint is advisable, to prevent the formation of adhesions. 

Scurvy is not strictly a disease of childhood ; but, of late, 
attention has been called to a scorbutic affection of the bones, 
often associated with moderate rachitic changes, and which 
has hitherto passed as acute rickets, chiefly from the de- 
scriptions given of it by foreign writers who had no knowl- 
edge of its morbid anatomy. Dr. Cheadle, from cases which 
have come under his own care, propounded the doctrine that 
the disease was a compound of rickets and scurvy. Dr. Gee 
has published cases evidently of the same kind under the 
name of " osteal or periosteal cachexia;"* and Dr. Barlow, 
in the Medico- Chirnrgical Transactions^ has considerably 
extended our knowledge of the subject by eleven additional 
cases, two of which are of the greatest value, for the writer 
was able, by a post-mortem examination, to demonstrate the 
actual nature of the lesion that existed. From these two 
cases, and another already published in the Transactions of 
the Pathological Society of London, by Mr. Thomas Smith, it 
is shown that the clinical features of acute rickets are asso- 
ciated, it is true, with moderate rachitic changes, but much 
more with extensive sub-periosteal hemorrhage in the bones, 
chiefly the femora and tibiae, scapulae, ribs, and cranium, and 
with a tendency to fracture, and sometimes with separation 
of the shaft from the epiphysis, as occurs in syphilis, acute 
necrosis, and perhaps other conditions also. 

The clinical symptoms are given in the following case, 
which was sent to me by Mr. Oram, of Clapham, and the 
nature of which I at once recognized, being fresh from the 
perusal of Dr. Barlow's paper : 

A child of fifteen months. Its father is a dark man, and, 

* St. Bartholomew's Hospital Reports, vol. xvii., p. 9. 
f Vol. lxvi., p. 159. 



PURPURA — HEMOPHILIA — SCURVY — AN/EMIA, ETC. 629 

Mr. Oram tells me, one of the most anaemic men he has ever 
seen. The mother is slim and small, but calls herself healthy. 
There is no rheumatic history. This is her first child. She 
nursed it for four months, and since then it has been fed on 
11 milk food." "The child cannot take milk." For many 
weeks it has been subject to effusions of blood in the cellu- 
lar tissue of the orbits. The effusion takes place quite sud- 
denly, and perhaps before it is reabsorbed a fresh one occurs. 
For a month or two it has been quite unable to move its 
limbs. It was not an anaemic child in any marked degree. 
Its head was rather rachitic, the anterior fontanelle open ; no 
craniotabes ; no bosses on the skull. The two lower incisors 
only were cut; the gums were normal; no purpura. Both 
upper eyelids were swollen out by large effusions of blood, 
giving a black eye on each side, and the left eye was promi- 
nent in addition, apparently from effusion of blood into the 
orbit. 

The child shrieked most painfully whenever it was 
touched, so that there was much difficulty in ascertaining 
where the most pain lay, but it was chiefly in the lower 
limbs. The radial ends were nodular the ribs moderately 
beaded ; the thighs and spine normal ; the knees also. 
The lower half of each leg was swollen, brawny-looking 
and indurated; the dorsum of the foot was cedematous ; the 
skin was pale and without any undue heat. It was impos- 
sible to be quite certain of any thickening of the bones, 
as the child's shrieks were terrible directly its legs were 
handled ; but the indurated feeling of the integuments, and 
their peculiar adhesion to the bone, not unlike the sensation 
of scleroderma, made me think that the bones were affected. 
The optic discs were healthy ; the urine was not examined; 
the liver and spleen were normal. 

Raw beef juice was ordered, underdone pounded meat, 
orange juice, and milk — the diet to be varied as much as 

53 






63O THE DISEASES OF CHILDREN. 

possible — and opium was given in small doses three times a 
day. The child rapidly improved ; and a month later it was 
free from pain, took its bath with pleasure, and moved its 
legs freely. 

This case corresponds in all essentials with those that 
have been described by others. There was plenty of evi- 
dence of a moderate degree of rickets ; but the brawny 
tension of the lower limbs from the ankle upwards, and the 
extreme pain, were as certainly something more than rickets, 
and corresponded with what has been observed by Dr. Barlow 
to be associated with sub-periosteal hemorrhage. Then 
there was the fact that it was supposed not to be able to 
take milk, and its diet had been nearly confined to artificial 
food ; at the same time there was no evidence of syphilis ; 
the parents were moderately well-to-do ; and the child 
rapidly improved by a simple change of diet, and by quiet- 
ing its pain by the temporary administration of opium. 

Diagnosis. — It is, perhaps, most likely to be mistaken for 
syphilitic disease of the bones. This, as is well known, is 
liable to occur at the epiphysial junction, and to spread as a 
periostitis along the shaft of the bone, and it leads to ab- 
scess and to separation of epiphysis from shaft. The ab- 
sence of any definite signs of syphilis, and the existence of 
rickets, with the history of bad feeding, might in most cases 
make us suspect the real nature of the affection ; but it may 
be also added that the brawny induration running gradually 
up the shaft is not quite what we meet with in syphilis, nor 
is the extreme pain of these cases often found to such an 
extent in the syphilitic bone disease of infancy. Moreover, 
as Dr. Barlow points out, syphilitic disease occurs at an 
earlier Sge than does acute rickets. 

Prognosis. — If treated properly, and not already too ex- 
hausted, these cases will get well, though the process of 
recovery is sometimes tedious. 



PURPURA — HAEMOPHILIA — SCURVY — ANEMIA, ETC. 63 I 

Treatment. — This resolves itself into variety in diet — 
such things as raw beef-juice, underdone pounded meat, 
orange juice, cauliflower, julienne, or milk, etc., being par- 
ticularly useful. 

Anaemia is a very common ailment in childhood. Natur- 
ally, both bad blood and poor blood are associated with all 
sorts of diseases, and are, in fact, amongst the symptoms of 
many ; but besides these morbid states of the blood, due to 
definite disturbances and changes in the viscera, it is no un- 
common thing to find that a child is anaemic, and there is 
no definite cause for it. The child may have been working 
hard, or playing hard, or growing fast, or the pallor may be 
the remnant of some preceding illness ; but whatever may 
be given as the explanation, the most careful examination 
fails to show any organic disease. 

Anaemia is common to all ages, from infants a few months 
old and upwards; and in younger children, from babyhood 
up to three years, it is often, but not always, associated with 
some enlargement of the spleen. 

The microscope usually shows a very abnormal state of 
blood in these cases : the red corpuscles are much dimin- 
ished in number, the white corpuscles are in slight excess, a 
number of small corpuscles stud the field, and there is also 
more or less granular matter. 

Diagnosis. — This must only be arrived at by a careful 
exclusion of every other disease. The child must be 
thoroughly examined; and only in the absence of actual 
structural changes in the viscera, in the absence of syphilis 
and ague, rickets, etc., is simple anaemia to be diagnosed. 

Prognosis. — Simple anaemia is sometimes very intractable, 
and one cannot but feel that, in such cases, the condition is 
a serious one. It is impossible that the blood can be seri- 
ously at fault for any length of time during the period of 
growth and development without harm. The difficulty that 



632 THE DISEASES OF CHILDREN. 

exists of gauging its exact influence upon this organ and on 
that does not make the risk any the less, and an anaemic 
child requires attentive treatment. 

Treatment. — The difficulty lies in getting at what is 
wrong; too often it is considered sufficient to give a tonic, 
chiefly iron, and this almost without inquiry. But, before 
resorting to drugs, investigation must be made of the per- 
sonal hygiene of the child — its disposition, its food, its sleep, 
its clothes, its habits, its play, its work, its home, and its 
environs, etc. Not till all these things have been considered 
can it be determined whether the requisite treatment should 
be by quinine, iron, arsenic, or cod-liver oil, or by more 
food, more air, less work, and so on. If careful inquiry be 
given to these matters, the treatment will generally suggest 
itself. 



RICKETS AND BONE SOFTENING. 633 



CHAPTER XLVI. 

RICKETS AND BONE SOFTENING. 

Rickets is one of those diseases for which familiarity often 
breeds a certain amount of contempt in the student's mind. 
" Only a case of rickets " is not infrequently his mental atti- 
tude in regard to it. It occurs so often, under conditions of 
home life which it may well-nigh seem hopeless to combat, 
amongst the poor, the ill-fed, the badly housed of our large 
towns. Nevertheless, it is a disease of much interest. That 
it is called Englische Krankheit may well make us study it 
thoroughly, and to a motive of this sort may be added that 
it is a cause of heavy infant mortality through bronchitis 
and its allies, whilst yet it is one of the most preventable of 
diseases. 

Etiology. — As with many another disease, so soon as we 
come to discuss its causes, although the evidence on the 
main points is unmistakable, there are yet subsidiary ele- 
ments which, w T hilst they are less certain, have, sometimes, 
in the heat of controversy, been allowed to obscure the light 
we have. Rickets is a diet disease, due to the prolonged 
administration of indigestible, and for the most part of 
starchy, food. It has been said, indeed, that rickets can be 
produced at will by the copious admixture of starch with 
the milk at a time when the child is unable to digest it. It 
is hardly so. In the larger number of cases atrophy and 
the death of the child are brought about by bad feeding. In 
some, and these also very common, Nature, so to speak, 
saves the ship from wreck, and the child is left to drag along 
in the sadly deteriorated condition we know as rickets. This 



634 THE DISEASES OF CHILDREN. 

much all will allow. It is only when we come to discuss the 
question as to what other influences are at work in the pro- 
duction of the disease that any uncertainty exists. But, for 
my own part, in matters so difficult of solution, I doubt the 
necessity of their discussion. It must be admitted that a 
deteriorated condition of health on the part of the mother, 
either during gestation, or while suckling the infant, is only 
too likely to conduce towards — perhaps actually to produce 
— rickets. I quite believe with Dr. Eustace Smith that un- 
duly prolonged suckling makes for rickets. One can as 
readily admit — the burden of proof surely lies on him who 
would not do so — that bad air, ill-ventilated rooms, want of 
cleanliness, are potent abettors of the disease. And syphilis 
also, in that it produces a much impaired state of nutrition, 
which often extends over many months, may surely help in 
the same direction. 

These are all questions which will have to be entertained 
in individual cases. These various elements of bad hygiene 
will then need to be very carefully appraised, and the direct- 
ness of success in treatment will no doubt depend much upon 
whether this be done well or ill. But the general question 
involved is untouched by them ; and rickets remains essen- 
tially a diet disease, unless, indeed, such a radical hypothesis 
be accepted as that of M. Parrot, that rickets is a manifesta- 
tion of infantile syphilis. *- 

I shall not discuss what may be the etiological formula for 
rickets in Paris or other large continental towns ; it will be 
sufficient for my purpose to say that in England rickets, as 
a disease, exists for the most part independently of syphilis, 
and it is not ameliorated in most cases by mercurials or iodide 
of potassium. 

The arguments in favor of its dietetic origin are, shortly, 
these. Changes in many respects like it are found in the 
lower animals kept in confinement and under artificial con- 



RICKETS AND BONE SOFTENING. 63 5 

ditions as regards their food. It is a disease of all large 
towns, more or less — that is to say, in proportion as the 
population increases, over-crowding occurs and the means of 
subsistence become more costly; then hand-feeding, and 
cheaper, less troublesome, and less valuable foods are sub- 
stituted for milk, and so we have rickets. Although called 
the English disease, it is by no means confined to this coun- 
try. It may be seen in most of the large continental cities, 
and in some is as common as it is with us. Lastly, it is a 
disease found, to say the least, in overwhelmingly large pro- 
portions, in hand-fed infants. Dr. Buchanan Baxter made 
some most careful inquiries on this point amongst the out- 
patients at the Evelina Hospital, and the result was that no 
less than ninety-two per cent, of the whole number had been 
given farinaceous food before the age of twelve months. The 
time of life at which the disease is met with forms an im- 
portant element on this head, and I have analyzed 141 of 
my own cases, to show the time of life at which the disease 
occurs : 

k 7 8 9 10 11 12 18 m. 2 T/ x/ ■ _, , --p . , 

1 2.V0. -3. 'vA 4^6 Total. 

m. m. m. m. m. m. m. under years /z ° 2/,i ^ D 

3 i 3 2 5 6 11 36 26 19 13 2653 141 

Sixty-eight w r ere boys, seventy-three girls. 

Dr. Gee* gives much larger numbers than these. Of 635 
cases (365 boys, 270 girls) 32 were under six months, 144 
from six to twelve months, 183 from twelve to eighteen 
months, 133 between eighteen months and two years, 116 in 
the third year, and 27 in the fourth year. And he further 
states that thirty per cent, of sick children under two years 
of age are rickety. 

This table only gives the age at which the child was 
brought for treatment. In most cases the onset of the dis- 

* On Rickets, "St. Bartholomew's Hospital Reports," vol. iv., p. 69. 



636 THE DISEASES OF CHILDREN". 

ease must have ante-dated the attendance by a considerable 
period. But it shows well how large a proportion of cases 
occur from ten months to two and a half years — that is 
to say, from weaning onwards through the period of denti- 
tion. 

It may be added here that some authors have contended 
for the existence ii> of foetal rickets, ('2) of rickets at birth 
(congenital rickets) and (3) of the rickets at the time of life 
here spoken of. As to foetal rickets, most authors consider 
it to be a form of cretinism; and the existence of con- 
genital rickets is but doubtful, although, as I have said, if 
exceptional, its occurrence seems possible. All agree that 
rickets is rare during the first two or three months of life. 

I have stated the case thus far somewhat dogmatically ; but 
it must be borne in mind that there is no single fact in con- 
nection with rickets which has not been at some time or 
another, and which is now, disputed by this authority or that. 
There are some who think the disease a diathetic one — 
one, that is to say, passed on from parent to child, in 
large measure independent of and incapable of production 
by external agencies alone. And some observations of 
Ritter von Rittershain show that rickety children frequently 
come of mothers who still bear traces of having suffered from 
a similar disease. It is also said, and the same author, to 
some extent, countenances this view, that tubercle is asso- 
ciated with rickets. Trousseau held that the two were mu- 
tually exclusive. But there can be no doubt that tubercu- 
losis is not uncommon as a sequel to rickets, although, as 
Hillier says, the two conditions seldom go on actively at one 
time. 

Others hold, as I have done, that it is dietetic; others, 
still more rigorously, that it is not only dietetic in a general 
way, but due to the administration of starch in particular; 
others, again, lay stress on feeble health in the mother dur- 



RICKETS AND BONE SOFTENING. 637 

ing gestation or lactation; others upon bad air, want of 
light, insufficient clothing, want of cleanliness, etc., and so 
on. Arguments quite worthy of consideration have been 
used for and against all these hypotheses by observers, of 
whom it will be enough to say that their names include 
some of the brightest ornaments of medicine and pathology 
in this and other countries. But upon a reflective study of 
much that has been written, the short summary I have given 
seems to me a fair and reasonable one; although I should 
not wish the student to suppose that it could not be dis- 
sected, and arguments advanced against some of the conclu- 
sions arrived at. 

Symptoms. — Rickets is, for the most part, a slowly 
progressing general change in the tissues and the viscera, 
which runs an insidious apyrexial course. In the earlier 
stages of the disease the symptoms are somewhat vague. 
Diarrhoea, restlessness during sleep and a tendency to throw 
off the bedclothes ; profuse sweating of the head, neck, and 
chest; causeless crying when the child is moved, and a 
flabby condition of the muscles of the arms and legs, com- 
bined often with an excessive amount of subcutaneous fat, 
are amongst those which at first are the most noticeable. 
Later on, the ribs become beaded, the wrists, knees, and 
ankles enlarge (Dr. Marshall has even noticed the knuckles 
to enlarge), the shape of the head becomes characteristic, 
the nervous system irritable, and, in the latest stage, the 
child wastes, the ribs fall in, the spine and long bones curve, 
the liver and spleen become enlarged, and death may 
happen from bronchitis, broncho-pneumonia, convulsions, 
etc. But the symptoms must be considered in rather more 
detail. 

The head in rickets is often characteristic ; the veins 
upon the forehead stand out full of blood ; the fontanelle 
bulges and is unduly open ; but the head is elongated from 

54 



638 THE DISEASES OF CHILDREN. 

back to front, and its posterior segment enlarged. The 
head appears flattened in the temporal region, and the fore- 
head, although overhanging, is not expanded. Thus, in 
several points, it differs from the hydrocephalic skull, which 
tends to assume a globular shape, the temporal fossae bulg- 
ing in place of flattening, the forehead being expanded, 
and the frontal bone opening gently upwards to the globu- 
lar and bulging anterior fontanelle. Rickets may be com- 
bined with hydrocephalus ; but apart from this, the rachitic 
skull is latterly compressed, with prominences in the region 
of each frontal and parietal eminence. The cause of this 
has been much discussed, some attribute it to the fact that 
the child lies much on its back. By thus subjecting, the 
occipital bone to pressure, the posterior part of the skull be- 
comes flattened, and the brain is pressed forward against 
the frontal bone. This may be in a measure true, but it is 
also to be remembered that rickets is a disease which begins 
comparatively late — not till some months after birth — and, 
therefore, not until the centres of ossification in the skull 
have had a fair start. The regions of the frontal and parietal 
eminences are then comparatively well protected, and the 
growth of the brain will go on with less difficulty by length- 
ening the skull from before backwards, and also by pushing 
outwards as a whole the lateral halves of the skull cap. 
Moreover, the interfrontal suture unites before the end of 
the first year, and, should the rickety condition supervene 
at a later date — as is probably not uncommon — the growth 
of the brain will then more readily proceed backwards, and, 
by widening out of the parietal eminences, a head with a 
small square forehead and large posterior segment would 
be produced — the shape, in fact, which is a characteristic of 
the skull in many a case of rickets. 

I cannot forebear to add that the brain is not exempt 
from laws which apply to other parts, and that — like the 



RICKETS AND BONE SOFTENING. 



639 



foot of the Chinese lady, which takes its shape from the 
appointed boot — it grows best along the lines of least re- 
sistance. Can anything of greater significance be suggested, 
where convulsions of varied kind form one of the chief fea- 
tures of the disease? It can hardly be a matter of indif- 
ference whether the growth of the brain is allowed to pro- 
ceed as it should do, or whether by an early closure, say of 
the frontal or sagittal suture, the posterior parts are made 
to develop in disproportion to the front, or some part of the 
latter is placed under disadvantage. The size of the skull 
has usually been said to be increased in rickets, but Ritter von 
Rittershain, on the ground of careful comparative measure- 
ments, denies that there is any enlargement. The head 
often appears to be large, but this is due to the peeky face, 
the stunted limbs, and bad nutrition. Trousseau taught 
that the large skull went with precocity ; but if the skull 
be not really enlarged, that contention falls to the ground ; 
and if it be, the precocity is of a very shallow kind in most 
cases — it is more true to hold, with Gee, that the brain is 
usually dwarfed. Sir W. Jenner ascribes the prominent 
forehead to infiltration of the anterior lobes of the brain 
with albuminoid material. This must, however, be a very 
rare condition, whereas the prominence of the forehead is a 
very common feature of the disease. I believe the explana- 
tion I have given, that the brain pushes the segments of the 
skull backwards and forwards, is more satisfactory for the 
majority of cases; while in some it is accounted for by an 
exuberant growth of soft bone on the frontal eminences. 

Hydrocephalus is said by some to be a frequent associate 
of rickets. I know of no facts which prove this. The fon- 
tanelle may remain widely open long after the period when 
its closure should be complete (this is given by Eustace 
Smith as the end of the second year, but in healthy children 
very little of a fontanelle should remain after the end of the 



64O THE DISEASES OF CHILDREN. 

first year), and it may bulge unduly, and frequently does so 
in rickets, but these things do not necessarily mean hydro- 
cephalus. At the same time, the onset of this disease would 
seem to be likely enough, for any delayed ossification of the 
skull to some extent predisposes towards the occurrence of 
a congested brain, or of hydrocephalus. 

Craniotabes, first described by Elsasser in 1843, has till 
lately always been held to be a sign of rickets. M. Parrot 
and others have called this doctrine in question, and con- 
sider the complaint a sign, not of rickets, but of congenital 
syphilis. Craniotabes, or wasting of the skull, is a condi- 
tion of softening of the bones, particularly of the occipital, 
by which, under moderate pressure from the finger, the 
bone caves inwards with a crackle like that of stiff parchment. 
It is of two kinds: in very young infants the bones of the 
skull will yield under pressure and sometimes crackle, but 
this is not a diseased condition. The true disease generally 
exists in localized patches. It is said to occur in thirty to 
forty per cent, of all cases of rickets, and is found to perfec- 
tion from six months after birth onwards. It is an open 
question how far this condition is due to uncomplicated 
rickets, and how far to syphilis ; but it is a remarkable fact 
that, since the question was mooted, some very weighty 
evidence has been produced in favor of its association more 
with syphilis than with rickets. Dr. Thomas Barlow and 
Dr. Lees collected 100 cases of craniotabes, and have pub- 
lished* the results of a most careful inquiry upon its rela- 
tionship both to syphilis and rickets. From it they conclude 
that forty-seven per cent, of the total are almost certainly 
syphilitic ; and to thfs may be added the observation of Dr. 
Baxter,! that °f tne twenty-three per cent, of craniotabes 
in rachitic children, seventy-five per cent, were syphilitic. 

* " Path. Soc. Trans.," vol. xxxii., p. 323 et scq. 
f Op. cit.,?. 361. 



RICKETS AND BONE SOFTENING. 64I 

My own opinion inclines in the same direction. For a long 
time I examined for craniotabes amongst rachitic childr 
and, finding it so seldom, I was disposed to think it was far 
common than has been taught ; but then, bein^ en- 
gaged at the time on other obsen upon congenital 

syphilis, all cases that showed any traces or suspicion of 
that disease, even if associated with rickets, were, no doubt, 
- jd into the syphilitic group, and thus would have escaped 
notice. Certainly, in such cases as I have known in recent 
years, craniotabes has most often been, either in well-marked 
s of congenital syphilis, or in cases in which the suspi- 
cion of the existence of that dise? strong; but there 
A a proportion of cases in whic jch taint can be 
shown to exist, and I should suppose it to be one of those 
conditions for which a combination of circumstances, if not 
necessary, at least is most favorable to its production. 

In this regard it is important to remark that experienced 
obse tote that craniotabes is : invariably asso- 

ciated with laryngismus. Now laryngismus is univers: illy 
admitted to be almost always due to rickets. I do not know 
that anyone has asserted it to be due to syphilis; so that, if 
the two are thus closely :ed, the fact is clearly in 

favor of the rachitic nature of craniota:: 

The skull of a child affected with craniotabes shows shal- 
low depressions at the diseased pai ;:hiy bevelle 
into the surrounding bone. The depressed areas may be so 
numeroL: iner table a somewhat trabeculated 
appearance. The thin layer of bone which covers in the de- 
pression is that which gives the crackle as it bends inwards on 
pressure. In some cases the thinning is more genera'., in- 
volving, perhaps, the entire occipital bone ; in others, the 
local thinning is considerable, and may go on to the forma- 
tion of a number of membranous opercula. In other c 
again — and the real nature of such is still open to question 



642 THE DISEASES OF CHILDREN. 

— there is much tendency, not only to thinning and soften- 
ing, but to the formation of new bone, in most cases leading 
to the production of a velvet-pile-like layer of osteophyte 
over the surface of the bones between the sutures and the 
centres of ossification. In this way the sutures come to form 
furrows, and the calvaria assumes the shape of a hot-cross 
bun — the natiform skull — and sometimes the bone formation 
may be so active that the skull may reach a thickness of 
half an inch or more. The new bone is very soft in all these 
cases, can be cut with a knife, and is of a peculiar claret 
color, from the amount of blood it contains. Many, as I 
have said, consider this condition of the bones of the skull 
to be a sign of congenital syphilis. It is certainly frequently 
found in syphilitic infants — in infants in whom other evi- 
dences of rickets, though not absent, perhaps are of the 
slightest. Nevertheless, I do not think one can altogether 
exclude rickets from at any rate an occasional share in its 
production. 

Epiphysial Lesions. — Other signs of rickets are found in 
the epiphysial extremities of the long bones and in the ribs. 
In these the ossifying layer of cartilage at the junction of 
the epiphysis with the shaft, or in the case of the ribs at the 
junction of the costal cartilage with the bone, becomes 
swollen — sometimes enormously so — and thus is produced 
a characteristic swelling of wrists and ankles and a beading of 
the ribs. These symptoms, although present in most cases, 
are by no means remarkable in many. A child may be very 
rachitic as regards its head, and perhaps show a distorted 
thorax, enlargement of the spleen, and even curvature of its 
bones, whilst yet there is but little enlargement either of the 
ends of the ribs or of radius or tibia. 

The bones are soft in rickets, and thus come sundry char- 
acteristic distortions of spine, thorax, pelvis, and long bones. 
In the thorax a double curve is assumed, the ribs fall in at 



RICKETS AND BONE SOFTENING. 



643 



their junction with the costal cartilages, and a vertical depres- 
sion of considerable extent is produced in such parts of the 
thorax as are not supported by the solid viscera. The abdom- 
inal viscera prevent the falling in of the lower part of the 
chest; the lateral parts of the upper segment fall in consider- 
ably; whilst the sternum becomes rounded and prominent, 
and the antero-posterior diameter of the chest becomes the 
dominant one. Some have distinguished between this, the 
chest of the rickety child, and the distortion due to other 
causes, such as atelectasis, or non-expansion of the lung. 
In the latter the ribs yield generally from their angles for- 
wards, and the chest becomes of a peg-top or angular 
shape, from the sternum becoming carinated. I must con- 
fess, however, to have had much difficulty in thus separat- 
ing two distinct classes of cases. On a priori grounds it 
may be argued that the softened bone curves, not only at 
the epiphyses, but also generally in its length ; there is 
ample evidence that it actually does so ; and there seems 
little reason why the ribs should not thus yield. The worse 
the rachitic condition, so much the more yielding will there 
be, and the lateral grooves will then be pronounced. In 
the less severe cases the recession of the chest-wall will be 
less, and the chest will approach the angular type. More- 
over, I am by no means sure that this shape does not repre- 
sent a partial obliteration of the more marked distortions. 
It is much more common in children of six, eight, or ten 
years. The grooved chest is the common type of infancy. 
It is certain that, as the child grows and the bones harden, 
the deeper dip of the ribs at the costo-chondral articulation 
gradually expands again ; while the antero-posterior expan- 
sion of the lung is in a measure permanent, and tends to 
perpetuate the prominence of the sternum. Of the pelvis I 
would speak in the same way. The pelvis of mollities is 
beaked, or Y-shaped, that of rickets is contracted in its 



644 THE DISEASES OF CHILDREN. 

antero-posterior capacity by the sacral promontory being 
unduly prominent. But in extreme cases of rickets, when 
the body weight has been unduly thrown upon the pelvis, 
the acetabula may be forced backwards into the pelvis, and 
a beak be produced by the symphysis and pubic bones. 
The femora and tibiae bow outwards and forwards ; the 
radius and ulna curve outwards ; and in extreme cases the 
natural curves of the clavicles become much exaggerated. 
These conditions go with (sometimes they may be replaced 
by) an unnatural relaxation of the ligaments, particularly at 
the knees, and thus cause the knock-knees and bandy-legs 
that are so often seen in late cases of rickets. 

A good deal of discussion has been carried on as regards 
the cause of all these deformities. Some have contended 
for muscular force acting upon soft bones ; others for simple 
weight — the bones, not being strong enough, yielding under 
the weight they are called to support. Both these forces are 
probably entitled to some consideration ; but the theory 
which attributes the curvatures to undue weight is no doubt ' 
the more important, and most of the curvatures may be 
understood and explained by a consideration of the direc- 
tion in which the force has acted. In one case it may be 
the weight of the body in walking ; in another, that of one 
part of the limb upon the remainder, as in lying down. In 
the arms it is due to those parts being used as a help to 
progression, the child moving on all-fours. In the thorax 
some have attributed the distortion to a combination of 
softening of the bones, with collapse of the lung, which is a 
frequent associate and consequence of rickets; others to soft- 
ening of the bone, and a yielding under the inspiratory pull 
of the muscles. Of this, however, there can be no doubt, 
that the deformity of the thorax is almost constantly associ- 
ated with bronchitis and atelectasis, and that in the bones 
of the spine and extremities curvatures never reach any ex- 



RICKETS AND BONE SOFTENING. 



645 



treme form in such as have not been allowed to walk or sit 
up unduly. 

Another important point as regards the rachitic skeleton 
is that the bones are stunted in their growth, and in ex- 
treme cases the child may be greatly dwarfed by this means. 

Muscular Symptoms. — The muscles all over the body 
are often excessively painful ; not only the muscles of the 
extremities, but those also of the back and abdomen. Pres- 
sure is very painful to these children, and they will often 
cry bitterly whenever they are moved. This condition is 
often present even before the changes in the bones are at all 
pronounced. Some cases are described as screaming when- 
ever any attempt is made to move them ; but I am inclined 
to think that in such there is likely to be some periosteal 
lesion, such as is described on page 624 as a combination of 
rickets and scurvy. 

Nervous Symptoms. — Convulsions, tetany, and laryn- 
gismus are in a very 4arge number of cases associated with 
rickets. Indeed, so commonly is this the case, that laryn- 
gismus particularly is thought by many to be always rach- 
itic. All these affections are described elsewhere — convul- 
sions and tetany as diseases of the nervous system, p. 537, 
and laryngismus under the head of laryngeal spasm, p. 309. 

Zonular cataract, where some of the strata of the lens 
between the nucleus and the cortex become opaque, leaving 
the margin and the central part clear, is a liability which 
attaches to infantile convulsions, and therefore to rickets 
Why this is so, we know not. 

Glandular Symptoms. — The lymphatic glands all over 
the body become slightly enlarged and assume a shotty 
feeling in rickets, and, although- it cannot be said to be 
common if we compute the entire number of rachitic chil- 
dren, an enlarged spleen and anaemia should always direct 
our attention to rickets as one of their causes. 

55 



646 THE DISEASES OF CHILDREN. 

Dental Symptoms. — Dentition is much delayed in rickets. 
A child of two years old may perhaps have no more of the 
milk teeth than the incisors and a molar or two, and these 
all more or less decayed. Delayed dentition is a valuable 
sign of the more moderate forms of rickets, which might 
otherwise pass unnoticed. The enamel of rachitic teeth is 
bad or rocky or pitted in its disposition ; the teeth are 
notched, or have horizontal ridges, and break away down to 
the gum, where they appear as black jagged stumps. These 
conditions are not peculiar to rickets ; they in all probability 
occur as the result of any severe or prolonged state of ill- 
health in infancy. 

The urine is said to contain too little urea and uric acid, 
and an increase of the earthy phosphates ; though this 
statement has been called in question by Rehn and See- 
mann. 

Complications. — These are chiefly two — bronchitis with 
atelectasis and diarrhoea. The association of rickets with 
scurvy is important, but not common. The occurrence of 
bronchitis is readily explained by the softened ribs and the 
distorted chest ; these entail atelectasis and emphysema, 
which in turn entail bronchitis ; the disease in the tubes, by 
still more preventing the ingress and egress of air, increases 
the amount of collapse, and the increasing collapse tends to 
increase the catarrh, and the collection of a muco-purulent 
secretion in the tubes. The causes of the diarrhoea can be 
less precisely stated ; but in an unhealthy child, with un- 
healthy secretions, congested viscera, diseased lymphatic 
glands, and severe disease of the bones — which are, at this 
time of life, most important elaborating organs for maintain- 
ing the blood at a normal standard — the existence of diar- 
rhoea is at any rate no cause for surprise. 

Scorbutic or acute rickets has been alluded to towards 
the end of the last chapter, p. 628. 



RICKETS AND BONE SOFTENING. 



e-47 



Morbid Anatomy. — If wc take the epiphysial end of a 

moderately rickety bone — of the rib, for example — and 
make a section through the length of it and its adjacent 
cartilage, comparatively healthy bone is seen* on the one 
side, healthy cartilage on the other, and between the two a 
layer, more or less thick according to the severity of the 
disease, of blueish or pearl-grey translucent cartilage. The 
line of this towards the cartilage is regular, but streaked 
with large vascular lines; towards the bone it is irregular, 
and sometimes so much so as to intersect the bone immedi- 
ately adjacent, and to appear as islands of cartilage, with 
vascular and calcareous points scattered about. On further 
examination, the adjacent layer of bone is seen to be paler 
or yellower than normal, and more rarified. The superficial 
layer of the periosteum is unaffected — it can be peeled off 
the bone beneath, leaving a continuous surface ; but beneath 
it, on the bone adjacent to the cartilage, there is more or 
less of a vascular soft material, prolonged upon it for a 
short distance, and imperceptibly lost as the cartilage re- 
cedes. 

The pearly layer of swollen cartilage causes the beading 
of the ribs and the enlargement of the ends of the long bones 
so well known in rickets ; and as regards the former, it is 
always mpre marked on the pleural aspect, because the 
thoracic walls bend inwards at this point, and make a 
knuckle towards the lung. The bone elsewhere is softer 
and more rarified than usual, and the fatty appearance of 
the medulla is replaced by one of a more vascular sort. 

Under the microscope, an excessive activity of the carti- 
lage is observed. The cartilage cells become swollen and 
largely increased in number; but instead of making good 
bone, a process of calcification goes on in them, and the in- 
terstices between them become filled with a vascular mar- 
row instead of with natural bone. These medullary spaces 



648 THE DISEASES OF CHILDREN. 

are continuous with the channels in the shaft, and thus is 
formed a spongy tissue, very vascular but with little bone in 
it. A similar process goes on in the vascular tissue under 
the periosteum : osteoblasts may be seen in all parts, but 
there is but little bone. 

The essential features of the bone changes in rickets, 
therefore, are excessive activity of growth of that cartilage 
which makes for bone, and the production of a large quan- 
tity of vascular embryonic tissue, or medulla. It can then 
be readily understood that, so soon as the rachitic condition 
— whatever it may be — is neutralized, all things are in favor 
of rapid ossification. This is what actually happens in many 
cases : the epiphysical lines ossify so quickly that the growth 
of the bone is curtailed by the perfection of the repair, and 
thus bygone rickets is likely to be represented by a stunted 
but unusually hard and ivory-like bone. As I have else- 
where implied, the rachitic process is either not always of 
the same intensity, or it varies somewhat in different regions ; 
and in the skull and spine there would seem at all times to 
be a probability of the production of more growth than in 
other parts, although still a soft spongy bone of indifferent 
quality. As regards the process of repair in these regions, 
it is difficult to speak ; but from the not uncommon occur- 
rence in adults of dense ivory-like skulls, and spines with 
eburnated surfaces, which want an explanation, it is proba- 
ble that a similar course is pursued, in at least some, to that 
which goes on in the bones of the extremities. 

From what has been said, it follows that there must be a 
considerable alteration in the chemical constituents of rickety 
bones, and analyses show a considerable deficiency of the 
earthy salts. 

Of other morbid appearances found in rickets not much 
need be said, as they are described in other places in this 
book — not much can be said, so little is known about them. 



RICKETS AND BONE SOFTENING. 649 

Changes in the brain have been described, such as albu- 
minoid disease and chronic cerebritis. Both conditions must 
be very rare. Of hydrocephalus, again, as a post-mortem 
occurrence — except as following upon convulsions and some 
organic disease, and possibly in this way dependent upon 
rickets — I think the frequency must have been deduced from 
such clinical features as distension of the fontanelle and ful- 
ness of the vessels of the scalp. But the meaning of these 
symptoms alone in any case is decidedly equivocal, as I have 
attempted to show in dealing with hydrocephalus. 

The lymphatic glands undergo some change, probably of 
a fibroid nature, and reveal this by an indurated, scarcely 
enlarged condition. It is supposed, though without ade- 
quate proof, that this change is of a similar nature to that 
which the spleen and liver undergo. The albuminoid dis- 
ease of all these viscera had been described as a glue-like 
change peculiar to this disease; but the observations of Dr. 
Dickinson and others, already quoted in Chapter XXIX., 
make it clear that the actual change in the viscera — and it is 
more common by far in spleen than liver, and, I think, than 
in lymphatic glands — is an increase in the fibroid material 
which constitutes the connective tissue of the organs, and it 
differs in no respect from that of the chronic enlargement of 
the viscera met with sometimes in ague, etc. The disease 
of the spleen, commoner though it is than that of the liver, 
cannot be called common. At most I have only notes of 
forty-four cases, and in twenty-four of these the rachitic na- 
ture of the general ailment was doubtful. It would seem, 
therefore, that the changes in the viscera can hardly be an 
essential of rickets, and probably Gee is correct in consider- 
ing them due to some pre-existing conditions, which, pet- 
haps, they share in common with rickets. 

The condition of the blood in rickets has received but 
little attention. Chemically, it has practically received none. 



65O THE DISEASES OF CHILDREN. 

I have made numerous microscopic observations upon the 
blood of rachitic children, and the changes in it are certainly 
remarkable. In some there is a simple deficiency of cor- 
puscles ; in some a deficiency of coloring matter ; in some 
the blood is crowded with a granular detritus ; and in some 
the corpuscles are represented by four or five different sizes. 
We are surely justified in assuming that these appearances 
indicate immaturity, poverty, and increased waste of the 
blood, when such are the exact conditions we should expect 
from what we know of the surroundings amongst which 
rickets finds its home. These must produce an inferior qual- 
ity of the circulating fluids, and an inferior quality of blood 
will produce a deteriorated bone ; the converse also holds 
true — bad bone will make bad blood, and the lymphatic 
glands and spleen are therefore doubly likely to suffer some 
chronic changes of the kind that are known to keep com- 
pany with blood diseases. 

Such being the morbid anatomy of rickets, what opinion 
can be arrived at as regards its pathology? In this regard 
one point in the histology of the disease seems to me to be 
pre-eminent — that the departure from the normal is one of 
perverted development. It is a disease only in so far as the 
material formed is not the best suited to the requirements of 
the body. This is important, for some pathologists are 
inclined to put all soft bones into one category. For such, 
rickets, mollities ossium, and the senile fragility of bone, 
which is not uncommon, are all related to each other; dif- 
fering chiefly in the age of the affected person — for whom, 
perhaps, the missing link to bridge the two periods of life 
may be found in what has been called " late rickets." Surely 
this is disproved by a study of their morbid anatomy. Rickets 
is clearly an arrest of development ; mollities is a degenera- 
tion of formed material. There can be no question that there 
is some truth in the remark that rickets can be produced by 



RICKETS AND BONE SOFTENING. 65 I 

feeding an infant on starchy food before it can digest it. No 
known condition of bad feeding will produce mollities os- 
sium ; diet a case of osteitis deformans how we will, no 
impression is made upon the disease, and both this disease 
and mollities are quite beyond our knowledge and our 
power. 

Many suggestions have been offered as to the cause of 
defective bone formation in rickets. Perhaps the most 
favorite one has been that an excess of lactic acid exists in 
the blood. Experiments were conducted upon animals by 
feeding them on phosphorus, while phosphate of lime was 
withheld from their food. This treatment produced rickets, 
it was supposed by the phosphorus acting as a stimulant to 
the would-be-bone, which was thus compelled to make 
bricks without straw. It is suggested that lactic acid, formed 
in the alimentary canal from milk and other food, may act 
in the same way, the materials for proper bone being want- 
ing. But no excess of lactic acid in the blood has ever been 
found. On the contrary, the latest observations make its 
presence extremely doubtful ; and the cause of the disease 
has by some been maintained to be a deficiency of hydro- 
chloric acid. The intimate pathology of rickets is still un- 
known. But if we dismiss the question, how T the softening 
of bone is effected, there are facts in the disease which are 
remarkably suggestive in attempting to frame a pathological 
conception of the conditions which determine it; and chief 
of these is this most remarkable fact, that rickets, qua rickets, 
invariably recovers if treated properly — that is, essentially, 
if the child be put upon a proper diet. There is, perhaps, 
no other argument of equal force in favor of the disease 
being due to something which is withheld — in favor, that is, 
of the disease being dietetic. 

Diagnosis. — When the bone changes are moderate the 
disease is frequently overlooked, and passes for mere back- 



652 THE DISEASES OF CHILDREN. 

wardness, weakness, etc. Rickety children are often 
plump in the earlier stages ; afterwards, they become flabby 
and wasted. Apart from such general considerations as 
these, two or three errors in particular have to be avoided. 
One, of mistaking inflammatory and sanguineous effusions 
beneath the periosteum for simple rickets, as has no doubt 
frequently been done under the name of acute rickets (see 
p. 628). Another, of confounding the bone changes of con- 
genital syphilis for those of rickets. And lastly, many 
children are brought for paralysis, and inability to walk and 
dangling legs, in whom the whole disease is rickets. There 
may, indeed, be a greenstick fracture due to this cause; but 
apart from this, the pain and wasting of the muscles will 
produce a very complete inability to move the limbs, which 
may sometimes deceive an incautious observer. Bearing 
the fact in mind, a mistake can hardly arise. 

As regards the bone lesions of congenital syphilis, rickets 
— if we allow the nature of the changes in the skull to 
be an open question — is a cartilage producer, syphilis is 
a bone producer. Thus, syphilis produces more extensive 
and diffused thickening of the lower end of the diaphysis 
than does rickets. And further, the bone lesions of syphi- 
lis are destructive, leading to separation of the epiphysis 
from the shaft, and to the formation of abscesses. 

The Prognosis will always depend upon the extent of 
disease in the lungs and in the viscera. Given a case of 
uncomplicated bone disease, and it may be said almost in- 
variably to get well. On the other hand, splenic enlarge- 
ment, accompanied as it often is by a profound anaemia, will 
surely prove troublesome, and such a case may waste and 
die. Many such, however, do well eventually. The bron- 
chitis, with atelectasis and a distorted chest, is also a most 
serious matter. It is a great risk in itself, and it also pos- 
sesses a secondary risk in the liability that exists for the 



RICKETS AND BONE SOFTENING. 



653 



production of cheesy changes in the bronchial glands and a 
subsequent tuberculosis. 

Convulsions cause death in a large number of cases, 
although the risk may be much mitigated by keeping such 
cases under treatment. Laryngismus stridulus appears 
sometimes to cause death, although it is not always possible 
to be certain how far the fatal event has been caused by un- 
complicated laryngeal spasm, and how far by a general con- 
vulsion. 

Treatment. — In the first place, as will have been gathered 
from all that has gone before, rickets is a disease which may 
be prevented by the simple observance of such precautions 
as common sense would seem to dictate, without instruction. 
The child of a sickly or exhausted mother, with poor milk, 
will need additional food, according to the directions given in 
Chapter II. ; the child that is still suckled at two years of age 
must needs be weaned, and food of good quality supplied to 
it. In addition to this attention to the food, it is probably 
of hardly less importance to insist upon the most perfect 
hygiene; cleanliness, to the most minute detail, should be 
enforced ; a tepid bath should be given night and morning ; 
there must be no stint in the changes of the child's under 
linen and napkins; cleanliness must be observed in its bed- 
ding; cleanliness in its food and feeding apparatus; and its 
clothing must be thoroughly warm, yet not oppressive.* 
The air the child lives in must be attended to. The garret 
near the sky, hot, dark, and stuffy, is not the place for the 

* I have at page 54, alluded to the value of a knitted jersey, made at the 
suggestion of Dr. Lewis Marshall, of Nottingham, and which is most valuable 
in giving adequate covering and warmth to infants in lieu of so many folds 
of flannel bandage. This, and a pair of loose knitted drawers, cover the body 
completely, and form a light, warm underclothing admirably adapted for 
children. The " Elizabeth binder," as the jersey is called, is manufactured 
by Walker, Kempson & Co., of Leicester, and can be procured through any 
hosier or draper. The drawers are easily made at home. 



654 THE DISEASES OF CHILDREN. 

nursery. To prevent rickets, the rooms inhabited by the 
child must be well ventilated, not draughty, and though 
warm, never hot. Plenty of out-door exercise must be given, 
and if the neighborhood be unhealthy, the child should 
certainly, if possible, be removed to some dry and bracing 
place at the seaside or elsewhere. 

The treatment of rickets must follow the same lines; but 
more than this, for the stomach of the child that has been 
fed on bread and butter, arrowroot, corn-flour, potatoes, and 
water bewitched with the milk of one cow, must be educated 
back to the digestion of milk and such things as beef-juice 
and gravy. 

The diet for a rachitic child must vary with its age; but 
seeing that most cases come under notice at eleven or 
twelve months old and upwards, they are for the most part 
able to digest good milk well, and they have also arrived at 
a time of life at which, once in a day, they may take good 
gravy and custard pudding, broccoli, or cauliflower. Older 
children, of eighteen months or more, may have underdone 
pounded meat with well-cooked cauliflower and gravy. 
Eustace Smith gives a diet which cannot be improved. It 
is as follows : Breakfast; a breakfast-cupful of milk, with 
one or two teaspoonfuls of Mellin's food dissolved in it. 
At eleven a.m.; a breakfast-cupful of milk, alkalinized by 
fifteen drops of the saccharated solution of lime. Dinner at 
two ; a good tablespoonful of well-pounded mutton-chop, 
with gravy and a little crumbled stale bread ; or a good 
tablespoonful of the flower of broccoli, well stewed with 
gravy until quite tender, thin bread and butter, and toast- 
water to drink. Tea at six ; as at breakfast, or a lightly 
boiled yolk of an egg, if no meat has been given. 

But there are many rickety children who at two years of 
age have the development of a child of twelve months ; per- 
haps there is bad diarrhoea, vomiting, etc., etc. In such cases 



RICKETS AND BONE SOFTENING. 655 

the diet must be carefully adjusted to their condition. The 
amount of milk will perhaps have to be reduced, very likely 
jn great measure replaced by the cream and whey previously, 
recommended on page 50. In such cases as these, how- 
ever, much reliance may be placed upon beef juice as an 
additional article of diet. This is made as for beef-tea : 
A quarter of a pound of meat is to be finely minced and 
soaked in a quarter of a pint of cold water for an hour; it is 
then strained and well pressed through muslin, and the re- 
sulting fluid is given, either cold or warm, by the bottle or 
spoon. Should any repugnance to it be manifested, it may 
be generally disguised in an equal quantity of milk, or it 
may be sweetened with a teaspoonful of malt extract. It 
should be freshly made each day, the quarter of a pint being 
distributed over the day. 

As regards medicinal treatment, saving the presence of 
special symptoms, no drugs are so successful as cod-liver 
oil — which should be given in doses, from twenty drops 
upwards to half a drachm or a drachm three times a day, 
according to the age of the child — and iron. As regards 
the preparation of iron, some prefer the syrup of the iodide, 
others Parrish's food. I like the, already frequently recom- 
mended, syrup of the lacto-phosphate of lime and iron, as I 
am under the impression that children improve more rapidly 
with it than with other preparations. It may be given in 
half-drachm or drachm doses, well diluted. A teaspoonful 
of malt extract twice a day is another useful remedy, and 
orange juice or lemon juice, w r ell sweetened, is also of ad- 
vantage, and particularly, perhaps, in such cases as have a 
scorbutic tendency. 

The diarrhoea of rickets should be first treated by a pre- 
liminary laxative of fluid magnesia. Subsequently, if not 
relieved by the dieting and abstinence from starch, Formula 
9 or 10 may be given, and to either, if necessary, half a drop 






656 THE DISEASES OF CHILDREN. 

of opium to each dose can be added ;*or Formula 23 may- 
be given instead. 

The bronchitis, being of so much importance in these 
cases, must be treated carefully, even when it is of the slight- 
est. The child should then be kept in a warm room, the 
atmosphere of which is made moist by a bronchitis kettle. 
The bowels should be opened by an aperient, and warm 
fomentations (or poultices, if they be preferred) be applied 
to the chest. If there be much mucus in the tubes, an ipe- 
cacuanha emetic should be given, and subsequently carbo- 
nate of ammonium (F. 45), or other stimulating expectorant. 

Convulsions in any form must be kept at bay with bro- 
mide of potassium and chloral (as suggested at p. 540), while 
the general health is undergoing restoration. The ventila- 
tion of the nurseries requires special attention under These 
circumstances. More fresh air should probably be advised^ 
and the body should be sponged with cold or tepid water 
night and morning. There are cases no doubt in which it 
is necessary to steer between Scylla and Charybdis, for while 
it is important to reduce the undue nervous irritability by 
such measures as these, it is equally necessary to avoid the 
occurrence of those bronchial attacks which are so fatal. 

The deformities of the limbs in rickets are to be prevented 
by keeping the rachitic child entirely off its legs until its 
bones become stronger. To insure this, splints which render 
walking impossible must sometimes be applied ; but the less 
of splintjng the better. One of the essentials of rickets is 
muscular failure, and it is above all things necessary, while 
the bones are hardening, to keep the muscles in as healthy 
a state as possible. For this end it is hardly possible to 
take too much pains ; and shampooing or friction should be 
carried out regularly and thoroughly — the mother's or nurse's 
hand, well oiled, should gently rub and manipulate all the 
muscles of the trunk and extremities for half an hour regu- 



RICKETS AND BONE SOFTENING. 657 

larly night and morning; and such stimulating treatment as 
salt baths and rubbing with a soft towel should be used in 
addition. 

As regards the remedy for the completed distortions of 
rickets, it is important to remember how common these are 
in childhood, how rare in adult life; the inference being, as 
is well known to be the fact, that, except in extreme cases, 
Nature herself repairs the deformities as the bones grow and 
strengthen. But surgical aid is often necessary, by the ap- 
plication in various forms of elastic extension, by splints, and, 
as a last resort, by the rectification of otherwise irremediable 
curvatures of the limbs, by osteotomy, etc. 

It is yet necessary to mention " late*rickets " and " foetal 
rickets." But when, at the outset, the question arises, Do 
such diseases exist ? it will be apparent that not much is 
known about them. 

Late Rickets is a rare but well-recognized condition, in 
which the bones of children eight or ten years old soften and 
undergo extreme distortion. This form of disease, therefore, 
does not occur until the rickety period has gone by. Yet it 
is called rickets. Sir W. Jenner says : " I have seen rickets 
begin in children seven and eight years old." There is much 
difficulty in coming to a definite conclusion on such a point, 
for, on the one hand, there is no improbability in the occur- 
rence of a true rachitic condition at this time of life, seeing 
that the skeleton is still in an active state of development and 
growth — on the other, it is equally admissible to hold that 
some such condition of resorption of mineral matters and 
degeneration takes place as appears to happen in mollities. 

Symptoms. — These children are born healthy, and in 
some cases at least, they have come of perfectly healthy 
stock. The recorded cases show that up to a certain period 
they have been strong, and then, perhaps after some serious 
illness such as measles or scarlatina, in an insidious way, 



658 THE DISEASES OF CHILDREN. 

generally with more or less pain, the extremities have be- 
come bent. In more than one instance fracture has occurred 
in one or more of the bones. Then the thorax has flat- 
tened in, and thus the case has remained, sometimes for 
many years, with stunted growth, and sometimes also with 
childish intellect. In a few instances death has occurred, 
perhaps from bronchitis or some such thoracic affection. 

Morbid Anatomy. — Very few data exist on this head. 
Such as there are show (i) that in the majority of these 
cases the bones are exceedingly thin and brittle. This is 
seen («) from the frequency with which fractures have oc- 
curred, sometimes in several bones, from very insufficient 
causes ; and (/3) from observations such as that of Mr. Bar- 
well, who records that he operated upon one of these cases 
to remedy a deformity, and the chisel went through the bone 
with the greatest ease; while, on passing his finger into the 
wound, the bone was a mere thin shell, full of an excess of 
oil. 

(2) Another case is on record,* in a boy of eleven, who 
was subjected to examination by Dr. Hilton Fagge, Mr. 
Warrington Haward, and Dr. Drewett. These gentlemen 
considered the change to be identical with those of rickets. 
The wrist ends in this case were enlarged, the bones were 
much distorted, and the child was quite helpless. He sub- 
sequently died, and a post-mortem examination was made 
by Dr. Abercrombie and Dr. Barlow, and the epiphysial line 
of the bones was found thickened and irregular, as in com- 
mon rickets. 

(3) There is yet another case worth mention, in a girl of 
ten, under the care of my colleague, Mr. Davies Colley.f 
She had always been pale, thin, and delicate, and from an 

* A Case of Late Rickets, by Dr. Dawtrey Drewett : " Trans. Path. Soc, 
Lond." vol. xxxii., p. 386. 

f "Trans. Path. Soc., Lond.," vol. xxxv. 



RICKETS AND BONE SOFTENING. . 659 

early age the ankles. grew outwards and the knees inwards. 
The humerus fractured, and subsequently the femur, and for 
this, at the age of ten, she first came to Guy's Hospital. It 
was then found that the long bones were very tender and 
flexible, and that their outer shell" could be pressed inwards 
like the skull in craniotabes. The urine was much deficient 
in phosphoric acid, only one-third the normal amount being 
present : the calcium was in excess. She died, at the age 
of thirteen, from a suppurative pyelitis, due to the formation 
of phosphatic calculi. After death several of the bones were 
much distorted — some were hypertrophied and dense, others 
light and thin, and in some were tumorous-looking expan- 
sions of a light porous bone, with fibrous-looking tissue 
.intersecting them. The microscopical examination by Mr. 
Symonds showed a complete absence of compact tissue and 
of Haversian systems, a porous bone being filled by fibrous 
tissue. Mr. Symonds remarks that this development of 
fibrous tissue with great wasting of the bone agrees with the 
description of late rickets, as described by Cornil and Ran- 
vier, rather than with osteo-malacia. But if it agrees with 
late rickets, it can hardly be said to do so with that of com- 
mon rickets; and I have stated the case of late rickets in a 
threefold manner in order to show that, whether or not all 
these cases are related to each other, there are at any rate 
several kinds of disease included under this term — some 
" identical with rickets ; " some (and I think the major- 
ity), evidenced by atrophy and fragility of bone, very like 
osteo-malacia; some not quite like either, possessing in 
addition peculiar features, which make them difficult to 
classify. 

Besides cases such as have now been mentioned, Rehn, 
of Frankfort, has described a condition, which he calls In- 
fantile Osteo-Malacia, which differs in some points from 
ordinary rickets. The bones of the skeleton become thin, 



660 THE DISEASES OF CHILDREN. 

soft, and porous, and their medullary canals disappear before 
an advancing growth of soft porous bone. The bones so 
affected are quite readily cut with a knife ; but in the only 
two that were examined after death, there were distinct 
rachitic changes in the cartilage zone, though but moderate 
in degree. 

This state of things occurs in young children. A case 
that I suppose to have been of the same nature occurred to 
me in a girl of one and a quarter years. In the skull, the 
new growth and consequent thickening was enormous; a 
pile-like new bone gradually monopolized the diploic space; 
in the extremities, fusiform nodes were produced, in which 
more or less of the entire thickness of the shaft was con- 
verted into the same soft material. These changes were 
associated with pronounced rachitic changes in the ends of 
the bones, and some have considered the entire process a 
rachitic one ; but the marked degree of generalized bone- 
softening, and the enormous development of imperfect bone, 
are conditions which form no part of common rickets in the 
human subject. Bone changes, in many respects resembling 
these, have been found in unquestionably syphilitic infants. 
" But," borrowing the words of the committee that examined 
the specimens,* " that such are necessarily and solely syphi- 
litic appears to us in our present state of knowledge not 
proven. The apportionment of the effects produced sever- 
ally by rickets and syphilis in this and other cases cannot as 
yet be determined." Very much the same must be said of 
late rickets and its relation to osteo-malacia. Some cases 
more resemble rickets, others osteomalacia; but whether 
the real meaning of this be that the two diseases are the 
same, with now one part of the process now another in the 
ascendant; or whether we have several distinct diseases 

* Dr. Hilton Fagge, Dr. Barlow, Mr. Warrington Haward, and myself: 
" Trans. Path, Soc, Lond.," vol. xxxiv., p. 201. 



RICKETS AND BONE SOFTENING. 66 1 

which in anatomical change resemble each other, is un- 
certain in our present state of knowledge. Let the ob- 
scurity that surrounds the subject stimulate the reader to 
investigate these very interesting diseases. I ought to add 
that Dr. Judson Bury, of Manchester, has recorded a case 
of a female infant of eight months,* which, in the absence of 
any rachitic changes in the appearances in the medulla, in 
the thinning and easy fracture of the bones, is not unlikely 
to have been an example of true osteo-malacia. Dr. 
Thomas Barlow was kind enough to show me specimens of 
bones from this case, and the appearances closely resemble 
those of the osteo-malacia of adults, whilst those of rickets 
are absent. 

Prognosis. — This must be somewhat guarded. Fractures 
in these cases repair readily, so that there is no want of 
activity of a sort, although it is hardly of the kind that is 
required. Some of these cases have lived sufficiently long 
to pass out of notice, a few have died from bronchitic and 
other complications. 

Treatment. — They must be treated on the same lines as 
the rachitic patient, and it will be unnecessary to say more. 
Inasmuch as the bones fracture spontaneously with the least 
force, the greatest care must be taken to avoid all undue 
movement and exertion. 

Foetal Rickets. — The occurence of true rickets at birth, 
or congenital rickets, is very rare. Most authorities doubt 
whether it ever occurs, although, as I have said, one need 
not be surprised at the occasional occurrence of such a 
condition. Steiner mentions the existence of a specimen of 
rickety foetus in the museum of the Hospital for Sick Chil- 
dren in Prague, and other cases are on record ; but none 

* A Case of Osteo-Malacia in a Child: British Medical Journal, 18S4, 
vol. i.,p. 213. 

56 



662 THE DISEASES OF CHILDREN. 

are free from doubt, owing to the fact that foetal rickets, which 
has not till lately been distinguished, is probably not rickets. 
In foetal rickets neither the bone nor cartilage lesions are 
those of rickets, but they are those of cretinism. Mr. 
Shattock, however, considers that some of the cases illus- 
trate a condition of rickets which has begun and ended in 
utero. The characteristics of foetal rickets are : the facial 
appearance — the small forehead ; thick lips ; flat nose and 
pallor; the flat, spade-like hand; the extremely stunted 
bones, the latter on section showing relatively large cartila- 
ginous epiphyses, and the absence of any irregularity of 
cartilage next the bone, or, indeed, of any rachitic change in 
the cartilage of any kind. 



INFANTILE SYPHILIS. 



663 



CHAPTER XL VI I. 



INFANTILE SYPHILIS. 



Hereditary Syphilis plays a large part in the diseases of 
infancy, and is of great frequency amongst hospital out- 
patients. I shall describe the disease much as I have seen 
it, and from notes of 158 cases now before me. The ages 
of these children when brought for treatment were as fol- 
lows ; 



3 weeks 1 


8 weeks 10 


4 months 14 


9 


months 6 


4 " 2 


9 " 7 


5 - 6 


10 


4 


5 " 6 


10 " 8 


6 " 10 


11 


" 3 


6 « 6 


12 " 21 


7 « 6 


12 


" 2 


7 " 5 




8 « 7 







Ten others were between one and two years, and twenty- 
four cases occurred in older children. 

As is well known, syphilis is a common cause of miscar- 
riages and premature births, and it occasionally shows itself 
in the child at birth. But it is much more common in in- 
fants of a few weeks old, and from the fifth or sixth week 
up to the fourth month appears to be its favorite time. In 
most of such cases the tale is that " it was a beautiful baby 
born," and perhaps at a month, six weeks, two months, etc., 
a rash begins to appear. 

The symptoms are those of secondary syphilis in the 
adult, of the eruptive stage of an exanthem ; but they are 
somewhat less regular than in adults. As Mr. Hutchinson 
puts it, "the tertiary and secondary stages are sometimes 
strangely mixed " — to wit, the frequent occurrence of bone 
trouble in children at the same time as the cutaneous erup- 



664 THE DISEASES OF CHILDREN. 

tion. It is probable that the symptoms are more regular 
and more severe the more recently either or both parents 
have suffered from the acquired disease. 

When syphilis occurs at birth the child is likely to be a 
shrivelled-up mite with a feeble cry, and a skin of a coppery 
color with scaling cuticle. The mouth and lips may be fis- 
sured and thick, the edge of the anus or buttocks ulcerated, 
and the soles of the feet red or coppery and scaling. In 
the worst cases the entire body may be covered with moist 
and brownish scales or crusts, and here and there blebs 
containing serum or sero-purulent material — a state of 
things which has been called syphilitic pemphigus, though 
" bullous syphilide " would be more appropriate. Most of 
these very early and severe cases die. They take food 
badly, and become exhausted. 

If we take a case in somewhat older infants, if the disease 
be severe, except that the child will in all probability be in 
plumper and better condition, its surface will be much in the 
same state. There will probably be a raised coppery erup- 
tion, with delicate scales or scurf covering its surface, and 
with serpiginous margin, spreading over the head, face, and 
trunk. The eyebrows may have come out, the nose and 
lips will be thick and fissured, perhaps small mucous tuber- 
cles will be visible at the angles of the mouth or the corners 
of the eyes, the nasal mucous membrane thick and the child 
" snuffling " — some think from mucous patches here also ; 
there will very likely be bullae or small ulcers about the 
penis and scrotum, condylomata about the anus, and scales 
of some thickness about the soles of the feet, and possibly 
the palms of the hands. In these severe cases I think the 
liver and spleen are less likely to be affected. 

In milder cases there is snuffling, more or less of a squamo- 
tubercular rash or a coppery roseola of irregular blotches, 
with fewer scales ; perhaps a fissured anus, with condylo- 



INFANTILE SYPHILIS. 665 

mata. The syphilitic infant will sometimes present a dirty 
tint of face, called the cafe-an-lait tint; but this is more 
common in the severer than in the milder cases, in which 
the child, although the symptoms are so pronounced as to 
leave no doubt about the malady, may be plump and good- 
looking. 

Perhaps I should also add that the complex of symptoms 
is very varied. Let us take a few. In one case — a child of 
eight months — there was a well-marked cafe-an-lait tint, 
craniotabes, small circular ulcers in numbers round thq 
anus, and a history of snuffles. In an other, snuffles and 
craniotabes only. In another, a well-marked coppery scaly- 
syphilide round the mouth. In another, snuffles, thick lips, 
depressed alae nasi, and red indurated gummatous lumps in 
the skin of various parts of the body. In another, no evi- 
dence of the disease save condylomata and perhaps snuffles 
(this is a very common case). In another, a bullous erup- 
tion, followed by condylomata. In another, a diffused red- 
ness of the soles of the feet and the palms of the hands, 
with a faint maculation of the buttocks and legs. 

As regards the rash upon the skin in congenital syphilis, 
a gyrate scaly eruption, with slight thickening (the squamo- 
tubercular syphilide or syphilitic psoriasis) seems to me to 
be more common than a macular syphilide, or syphilitic 
roseola, as it has been called. A diffused redness and scal- 
ing of the soles of the feet is also very common ; so, too, 
are snuffling, Assuring of the lips, and mucous patches at 
the angle of the mouth, fissures of the anus, condylomata, 
superficial ulcerations over the buttocks and scrotum, inter- 
trigo, etc. As rarer conditions, furuncular eruptions may 
be mentioned — red indurated masses in the connective 
tissue — which suppurate, if at all, very slowly and by a 
small aperture in the skin. Sometimes the skin presents 
circular coppery patches, in the centre of which the cutide 



666 THE DISEASES OF CHILDREN. 

is slightly raised and translucent, looking as if about to 
form a bleb. In others there may be an annular eruption, 
with the skin in the centre healthy, and not altogether un- 
like patches of tinea. Bullous eruptions are not very un- 
common, but the bullae are often only represented by cir- 
cular or oval superficial abrasions or crusts. 

Once I have seen a condition intermediate between these 
two cases last mentioned — a child of four months, in whom, 
distributed over the body, but chiefly on face and scalp, were 
slightly raised circular flat brownish spots, which vesicated 
superficial!}*, and then dried in the centre into a brown crust. 
The condition spread by circular ripples, and left superficial 
ulcers, which rapidly healed under mercurial treatment. 

In bad cases the skin generally will assume a brown, 
thickened, wash-leathen' consistence, from diffused chronic 
dermatitis. 

Syphilis sometimes causes extreme anaemia. 

Laryngitis is very common, as may be judged from the 
frequency with which hoarseness is met with. Henoch 
attributes this, and no doubt with some probability, to the 
formation of mucous tubercles about the larynx ; but so far as 
is actuallv known, a more general thickening of the mucous 
membrane of the epiglottis takes place, such as is so 
common in adult life. Sometimes extensive ulceration 
occurs ; an instance of this, in an infant of four months, I 
have already recorded in Chapter XX., when dealing with 
diseases of the larynx. Somewhat severe laryngeal symp- 
toms occured eleven times in the series of cases given, but 
in one case I am not sure that the symptoms ma}' not have 
been due to iodism. The child was three months old, and 
was only taking fifteen drops of the syrup of the iodide of iron 
three times a day. This it had done for ten days, a grain of 
hyd. c. cret being given twice daily in addition." Suddenly, 
when the macular syphilide was disappearing, a most pro- 



INFANTILE SYPHILIS. 667 

fuse mucopurulent discharge began to come from the nose, 
with much hoarseness also, and subsequently angry boils 
appeared in various parts of the body. 

Hepatic and Splenic Enlargement occur not infre- 
quently, the latter far more commonly than the former. 
Dr. Gee says the spleen is palpable in about one-half the 
whole number of cases; I should not have put the propor- 
tion so high. It would appear that hepatic enlargement 
but seldom occurs by itself, for, of seventeen cases, eleven 
were simple enlargements of the spleen — in the remainder 
both liver and spleen were large. I have no note of any 
case of hepatic enlargement alone. 

Bone Disease. — For much that is interesting regarding 
the pathology of this form of syphilitic affection, I must refer 
the reader to what has been said under the head of rickets. 
I shall only repeat now that of late it has been contended, 
particularly by M. Parrot, that there is a syphilitic form of 
disease of the cranial bones, as well as one which attacks 
the epiphysial ends of the long bones. The disease of the 
cranium is characterized by a velvet-pile-like growth of bone 
upon the outer surface of the skull, which spreads over the 
bones around the anterior fontanelle, between the sutures 
and the centres of ossification. Thus the sutures come to 
form furrows, and the calvaria is bossed. In company with 
the new bone formation goes a process of softening and 
atrophy, and thus the occipital bone is usually, and the 
other parts are occasionally, thin, soft, and compressible 
(craniotabes). That this form of skull is found in syphilitic 
infants there is no doubt whatever; that it is found in syph- 
ilitic infants who are quite moderately rachitic there is also 
no doubt ; but whether it is ever present in infants who are 
free from all traces of rickets is doubtful ; and how much 
of the diseased process is due to the one disease, how much 
to the other, or how much to some combination of favoring 



668 THE DISEASES OF CHILDREN. 

influences, is very uncertain. This much, however, may 
again be insisted upon, that syphilis is an energetic pro- 
ducer of new, though oftentimes of bad, bone. Rickets is 
pre-eminently a cartilage former. The exuberance of bony 
deposit is therefore in favor of syphilis rather than of rickets, 
which, even in its reparative stages is not generally 
known by a propensity of this kind. The disease, as it is 
seen in the ribs, is difficult to distinguish from the changes 
of rickets, unless, as is sometimes the case, it occurs in parts 
of the bones other than those bordering upon the costo- 
chondral articulation. As to the lesions in the other bones 
there is less doubt. They are certainly, in the main, quite 
distinct from rickets. The bene at the junction of the epi- 
physis with the shaft undergoes a slow caseous inflamma- 
tion ; more or less periosteal bone is developed from the 
epiphysis upwards along the shaft, giving rise to consider- 
able thickening ; subsequently an abscess forms, and the epi- 
physis becomes separated from the shaft. At the same time, 
the medullary parts of the diaphysis undergo atrophic 
changes by the overgrowth of a gelatinous medulla, and 
there are also minor changes of irregular ossification and 
calcification, such as might be expected from such an inter- 
ference with the natural processes of ossification. Here, 
again, as compared with the usual run of rachitic bones, 
syphilis is known by the amount of bone which is found in 
the periosteum ; and in such cases as I have seen there has 
been no evidence whatever of the growth of cartilage which 
characterizes rickets. It has not been my experience that 
many bones are liable to be affected at once ; three times 
only out of seventeen was it so. In the series of 158 cases, 
seventeen were examples of bone disease, not including 
cases of what might be called nodes, but once or twice ab- 
scesses formed ; in one case both elbows suppurated. The 
elbow was the seat of the disease eight times ; the shoulder 



INFANTILE SYPHILIS. 669 

twice; the wrist thrice; the finger once; the knee twice; 
the middle of the shaft of the tibia once; the ribs twice ; the 
cranial bones twice. (The multiple lesions are counted 
separately). The spleen was enlarged in three cases of bone 
disease; the liver and spleen once. In most of the cases 
there were other well-marked evidences of congenital syphi- 
lis. 

The following case may be given as an illustrative one : 
A female child of six months was brought to the hospital 
for swollen joints of six weeks' duration. One child had 
been born dead, and when three months old this child had 
been covered with an eruption of some kind. The child 
was very small, with snuffles and a depressed nasal bridge ; 
the lower lip was deeply fissured, and the body was covered 
with small coppery blotches ; the buttocks were ulcerated ; 
the anus swollen and fissured. The two elbow joints, the left 
wrist and shoulder, both knees, and the left ankle, were con- 
siderably swollen, the joints being more distorted than is 
usual in rickets. The ulna and radius had a nodular thick- 
ening just below the articular surfaces of the elbow, the 
humerus a thickening above. A similar condition obtained 
in the other bones — viz., a nodular thickening just above the 
joint, and not quite continuous with the articular end of the 
bone ; the left knee and wrist were painful ; there was slight 
nodular swelling of the rib cartilages at the junction with 
the bones ; the spleen was hard, and extended down to the 
umbilicus ; the liver extended half-way to the umbilicus. 

The disease is one that occurs in very young children — 
from five weeks old. Three cases occurred in infants of two 
months and under ; five at three months and under ; three 
at four months and under; the remainder being six months 
or more. It causes a good deal of pain, and perhaps 
advice will be sought for the child, because, as in some 
cases of rickets, it cries whenever it is moved, or a limb ap- 

57 



67O THE DISEASES OF CHILDREN. 

pears to be paralyzed. When the disease has advanced 
sufficiently far to produce separation of the epiphysis, there 
may possibly be a faint crepitus obtainable. 

The immobility of the affected limbs has been called by 
M. Parrot syphilitic pseudo-paralysis, to distingush it from 
infantile paralysis of neural origin; but it must be added 
.that Henoch describes cases of paralysis — chiefly of the 
arms — in syphilitic infants, in which there were no evidences 
of bone disease. 

These cases must, however, be difficult to distinguish with 
certainty, because, in addition to the bone affection, the ten- 
dency to muscular inflammation — well known in adults — 
cannot be altogether excluded. 

There is, however, no reason to doubt that, as in adults, 
the nervous system suffers also in congenital syphilis, and 
Dr. Thomas Barlow has recorded two cases'* — one a female 
infant of a month old, with meningitis, arteritis of the cere- 
bral vessels, and choroiditis ; the other a male of fifteen 
months, with gummata on the cranial nerves and disease of 
the cerebral vessels. 

Ulceration of the Tongue, of all degrees, is very common 
in congenital syphilis, though I have more often seen a dorsal 
ulcer of some size and depth than a more superficial and 
generalized condition. 

Mr. Hutchinson, however, speaks of a diffuse stomatitis 
without ulcers, parallel to, and one may suppose part of, the 
general swelling which attacks the nasal mucous membrane. 

Of other rarer conditions, I may mention iritis and choroi- 
ditis as occasional occurrences, and a gummatous testis also. 
Henoch tells of several of the latter group of cases, and men- 
tions others recorded by different observers. 

The morbid anatomy of syphilis is seldom much. But, 

* Trans. Path. Soc, Lond., vol. xxviii., p. 287 et seq. 



INFANTILE SPYHILIS. 6/1 

although definite lesions form the exception, syphilis is a 
fertile source of infantile atrophy, and sometimes of multiple 
visceral lesions. For example, there may be pleurisy ; the 
lung may be in that condition of consolidation which has 
been called white hepatization (p. 351); the bones may show 
the changes already described; the liver may contain gum- 
mata, or, as is more usually the case, may be hard or elastic 
and large, not much altered macroscopically, but much so mi- 
croscopically — the lobular arrangement being broken up by 
a diffused fibro-cellular growth, which some have thought 
to be derived from Glisson's capsule, others from the activity 
of growth of the hepatic cells themselves. The spleen, in 
like manner, may be large, dark-colored, hard, and traversed 
by tough fibrous bands ; whilst, as rarer conditions, Coup- 
land has found in a female child of three months, not only 
gummata in the liver and lung, but also interstitial myocar- 
ditis and nephritis.* 

Sequelae. — Congenital syphilis, once cured, is not liable 
to relapse — at any rate, so far as the eruption is concerned ; 
though an occasional condyloma may show itself about the 
anus or angles of the mouth, perhaps a sore throat or a laryn- 
gitis. But the chief peculiarity about the disease is that 
sometimes, not very often, it shows itself by symptoms quite 
distinct from those which occur in infancy. Of these the 
more characteristic are interstitial keratitis and teeth of a 
peculiar shape and arrangement. But these go with several 
other signs — to wit, a stunted development, distorted bones 
(either bent or nodose), a sallow lack-lustre skin, a sunken 
nose, and a fissured mouth. There may even be deafness, 
aural discharge, ozaena, chronic ulceration of the palate with 
perforation into the nose, unhealthy abscesses in various 
parts of the body, which may give rise to nasty discharges. 

* Path. Soc. Trans., vol. xxvii., p. 303. 



6j2 THE DISEASES OF CHILDREN. 

Some of these cases are very puzzling; the thickened bones, 
with much irregularity of the surface, and perhaps curvature 
and caries, the unhealthy abscesses, and ozaena, compel us, 
in the absence of proof, to halt between syphilis and struma. 

Hutchinson calls these tertiary symptoms. Indeed, as in 
the adult, so also in the infant, the eruptive or secondary 
stage passes off, and health is regained, perhaps for good. 
Yet it may be after a variable interval further symptoms 
develop, such as those detailed. The lesions are usually 
symmetrical. The appearances of interstitial keratitis vary 
according as it is recent and acute or of old date. 

Hutchinson's description of the disease is practically as 
follows : In the acute stage both corneae are usually affected, 
and they become of a bluish opacity, due to the effusion of 
lymph into their substance. There is a zone of ciliary con- 
gestion, but no ulceration. There is considerable intolerance 
of light. The inflammation over the opacity clears consid- 
erably, but leaves opacities of a nebulous appearance, which 
are easy to overlook. The permanent teeth are peculiar, in 
being set with much irregularity, in being dwarfed, deformed, 
and tending to decay. The upper central incisors have a 
vertical central notch of a more or less crescentic shape; the 
canines are deformed, the crown of the tooth being peggy 
or pointed ; the molars may be dome-shaped ; all the teeth 
are small, and thus gaps are left between them. 

These various symptoms may be found at all ages, from 
seven or eight years up to eighteen or twenty, or even 
further. Hutchinson has repeatedly seen patients of various 
ages, from twenty to eight and twenty, become the subjects 
of syphilitic keratitis for the first time. 

Congenital syphilis is contagious, just as secondary syphilis 
in the adult is ; therefore no healthy woman should be allowed 
to suckle a syphilitic infant. 

Diagnosis. — The chief difficulty lies in the frequent failure 



INFANTILE SYPHILIS. 673 

of many of the characteristic symptoms. A large number 
of children have no symptom but snuffling, which is suspi- 
cious, but not pathognomonic ; others perhaps have cranio- 
tabes ; others laryngitis and an enlarged spleen, or an en- 
larged spleen and a dirty anaemic tint of the face, and so on. 
Thus it often happens that a doubt remains ; and this is so, 
even if the most careful inquiries be made as to the parental 
illnesses — sore throat, rheumatism, eruptions, miscarriages, 
etc. At all stages of its history syphilis trails the scent of 
scrofula, and the evidence one way and the other must be 
balanced as well as may be. 

Prognosis. — Many children waste and die during the pro- 
gress of the eruptive stage ; but, if seen early and subjected 
to treatment, a great many recover, and may lose all traces 
of the disease, save for such scarring of the face or trunk as 
may be left behind by the former eruption. The severer 
generalized bullous forms of eruption are highly dangerous, 
and, if a child wastes persistently under treatment, the danger 
is great ; the same is true if there be much diarrhoea, snuffles, 
or bronchitis; but, failing all these things, the child will 
probably do well. 

Treatment. — "The only certain cure for infantile syphilis 
is mercury," writes Henoch ; and probably in that short 
summary lies the kernel of the experience of all. The mer- 
curial may be administered either by giving it to the mother 
(a plan which has been advocated strongly by some, but 
which I prefer least of all, as too uncertain), by internal 
administration as gray powder to the infant, or by inunction. 

I have nothing to add to the statement of Dr. Eustace 
Smith, that in the hydrargyrum c. creta, or the liquor hy- 
drargyri perchloridi, we have two effective and easily borne 
preparations. The former maybe given in grain doses night 
and morning, with two or three grains of bicarbonate of 
sodium or bismuth ; and this dose may, if necessary, be in- 



674 THE DISEASES OF CHILDREN. 

creased to two grains of the mercurial. In case of diarrhoea, 
the solution of the perchloride may be given ; infants take 
it well in half- drachm doses, which may be gradually in- 
creased if necessary. 

The inunction is carried out by rubbing half a drachm of 
the mercurial ointment upon the abdomen,' back, or sides, 
and covering the part with a flannel roller afterwards. The 
child should be well bathed every morning with soap and 
warm water, before the daily inunction is made. 

Besides specific treatment of this kind, attention must be 
given to all those more general means which will ensure the 
preservation of the child's health. Its food must be attended 
to, and it should of course be suckled by the mother, if pos- 
sible. But here may come a difficulty. Supposing that she 
should show no signs of disease, is the child to be weaned 
for fear of contaminating her? This is a question that can- 
not be answered by a yes or no. It is held by some that 
the ovum can be infected through the father, and be born 
syphilitic, the mother all the while remaining intact. If that 
be the case, the answer must be yes. But, on the other hand, 
there is a strong a priori improbability of any such freedom 
being possible ; and there is also the fact, vouched for by 
many observers, that the infant thus syphilized in utero never 
contaminates the mother by suckling, although she may 
show no signs of having already been syphilized. If this be 
so, the answer will be no ; for the fact is inexplicable, except 
on the hypothesis that the mother is already proof in some 
way against infection, and this is certainly much the more 
probable belief. It is almost inconceivable that a foetus 
should lie in utero for many months, receiving from, and 
returning a constant blood supply to, the mother, without 
conveying the disease from which it is suffering, and which 
is known to be so easily inoculable. On the other hand, it 
is in consonance with all we know of infective disease that 



INFANTILE SYPHILIS. 



6 75 



the mode of introduction of the poison may lead to such 
modification of the disease as may render it more or less 
incapable of recognition. On the whole, therefore, it is prob- 
able that a mother that bears a syphilitic infant is proof 
against contagion, and may suckle her child if it be consid- 
ered advisable as, in most cases, it certainly will be. As a 
first thought, therefore, for the safety of the child, the 
mother's health must be attended to. Not at all improbably 
a little of the liquor hydrarg. perchlor. or some iodide of 
potassium may better her condition, and, while acting upon 
her, act upon the child through the medium of the milk; 
but all other means for improving her health, in the way of 
good food, fresh air, etc., must be adopted as well. 

If the mother is unable to suckle her child, then artificial 
human milk or goats' milk or asses' milk are the best sub- 
stitutes ; but Chapter II. and those which follow it will sup- 
ply all information on this head. 

Wasting, diarrhcea, and vomiting require the same kind 
of treatment that they receive under other circumstances, 
such as have been detailed in Chapters III., IV., and V. 

Of the local conditions, the enlargement of the liver will 
often readily subside under mercurial treatment. That of 
the spleen is much more troublesome, and its continuance 
is no warrant for the prolonged administration of mercury 
if all other signs of the disease are in abeyance. In the 
pneumonia and the bone disease of the syphilitic infant the 
specific must be continued, in the one case with stimulants 
such as carbonate of ammonium or alcohol, in the other with 
iron and cod-liver oil. The pneumonia is fortunately rare; 
but neither complication responds quickly to remedies, and 
a case of either kind, except where the bone disease is con- 
fined to the production of a natiform skull — which does not 
much influence the prognosis — must be treated as of doubt- 
ful issue. 



6j6 THE DISEASES OF CHILDREN. 

A large number of the troubles of infantile syphilis are 
shown upon the skin. Condylomata are perhaps the most 
common. The parts are to be kept scrupulously clean by 
frequent bathing and change of linen, remembering that 
syphilis is always ready to pounce upon seats of. local in- 
flammation; cracks, fissures, excoriations of any kind, are 
likely to lead on to ulceration or condylomata. Condylo- 
mata are to be kept as dry as possible, and dusted with 
calomel night and morning. The calomel may be used pure, 
or mixed with an equal part of oxide of zinc or the sanitary 
rose powder.* 

The same treatment may be adopted for the small patches 
which occur at the angles of the mouth. 

In the dry eruptions nothing is generally needed but the 
internal treatment. For such patches as are intractable, the 
mercurial ointment may be applied, or a dilute solution of 
the oleate of mercury — the 5 per cent, strength diluted with 
three parts of carbolic oil, strength 1 to 40. For the ecthy- 
matous sores that form over the trunk and extremities, and 
about the nails, the ung. hydrarg. oxid. rub. is as good as 
anything, and for some of these cases a mercurial bath may 
be given twice a week. Dr. Eustace Smith recommends that 
half a drachm of the perchloride of mercury should be dis- 
solved in each bath. After the more definite symptoms have 
subsided, the child will usually require a prolonged course 
of iodide of iron and cod-liver oil, not only with the 
object of keeping up its strength, but to ensure if possible a 
freedom from chronic disease of bone, ozaena, and such 
things as go under the general term of struma, and which 
blight the happiness, not only of the child, but -of many a 
family also. 

* A preparation of boracic acid, suggested by Mr. Lund of Manchester, 
and prepared by James Woolley & Son of that city. 



DISEASES OF THE SKIN. 677 



CHAPTER XL VI II. 

DISEASES OF THE SKIN. 

The skin diseases of children are so numerous, and the 
literature of dermatology is so extensive, that the subject 
does not readily lend itself to a manual which treats of gen- 
eral medicine. I must, however, refer shortly to those more 
common affections which are of every-day occurrence, and 
to some few of the rarer conditions such as I have met with 
personally. A fuller treatment of the subject will not be 
necessary, considering the many excellent manuals that have 
been written of recent years. 

As a preliminary, let me say that perhaps there is no organ 
of greater importance than the skin in childhood. It is in 
many cases a most sensitive index of inefficient working 
elsewhere; its suggestions as to constitutional peculiarities 
are often of the utmost value to the physician ; when not 
properly cared for it readily goes wrong ; and rough hand- 
ling is quickly resented. Its very activity is a source of 
danger if it be neglected, and many of the diseases of the 
skin in infant life are directly chargeable to neglect. There- 
fore, as a general principle, it is of the first importance to 
attend to scrupulous cleanliness. A good bath once a day 
is not too much for any child, and a bath night and morning 
should be given to young children. Most children perspire 
readily and excessively, particularly during sleep, and re- 
tained perspiration about the neck or in the groin, etc., pro- 
duces first miliaria, and then intertrigo. Plenty of bathing 
and the use of the sanitary rose powder, in such parts as are 
liable to retain the secretions, will no doubt avert many a 



678 THE DISEASES OF CHILDREN. 

case of what would otherwise prove a troublesome eczema 
intertrigo. 

Warmth is another essential. Custom has prescribed that 
young children shall wear low dresses, short sleeves, petti- 
coats, and no covering at all for the lower part of the abdo- 
men and thighs, save a pair of linen drawers. This is a 
custom framed upon a weakest-goes-to-the-wall principle, 
which is opposed to the very raison d'etre of medicine. 
Children's clothing is to be light and loose and warm. The 
method of accomplishment of these aims hardly needs a 
more detailed statement. 

The more common affections of the skin are: Lichen — 
often called strophulus or lichen urticatus, from its almost 
inseperable connection with urticaria — eczema, impetigo, 
ecthyma, furuncular eruptions, herpes of all patterns, ery- 
thema likewise, psoriasis, tinea, alopecia, and molluscum 
contagiosum. 

Of rarer occurrence are pemphigus, ichthyosis, lupus, 
keloid, erysipelas, scleroderma, xanthelasma, and favus. 

Lichen urticatus, or strophulus, the red gum and white 
gum sometimes talked of, occurs chiefly from the age of 
five or six months onwards through the period of dentition. 
It is not unusual from two to four years, but its history may 
then be traced from a much earlier date; and even in older 
children, of eight, nine, or ten, a persistent lichen urticatus 
is occasionally met with. As seen in infancy, it occurs as 
rather sharply raised, whitish, rounded papules of a peculi- 
arly hard or shotty feel, and often with a translucent centre, 
looking like a vesicle, but from which no fluid comes when 
pricked. The forearms, legs, and trunk are its favorite sites. 
It is very irritable, and associated often with urticaria, and 
for this reason the appearances vary, the characteristic 
papules becoming lost in wheals or changed into a number 
of bleeding or crusted points, from the excoriation produced 



DISEASES OF THE SKIN. 679 

by scratching. Closely allied to this disease and to urticaria 
is another, which has been called urticaria pigmentosa, or 
xanthelasmoidea, in which the trunk more particularly be- 
comes covered with yellowish-brown blotches, the skin at 
the affected spot being raised and thick, like soft leather. 
Urticaria wheals are frequently seen about the body, and 
the history is often that the pigmented thickenings have 
begun as such — a fact as to the truth of which I have on 
more than one occasion satisfied myself. This disease was 
first described by Dr. Tilbury Fox as xanthelasmoidea, and 
a good many cases have since then been recorded. Dr. 
Colcott Fox has given a careful summary of all these,* and 
in addition has added important information on two points 
— first, he shows that the disease tends to disappear as the 
child grows up ; and secondly, that the microscopical struc- 
ture of the affected tissue is that of a wheal. 

It is important to recognize in all these three affections 
that the difficulties of treatment lie less in the actual struc- 
tural changes in the skin than in the fact that all these chil- 
dren have what Hutchinson calls a pruriginous skin. The 
subjects of urticaria pigmentosa have, not only a pruriginous 
skin but, also, as some cases of pemphigus, a peculiar ten- 
dency to the deposition of pigment in the skin. It is the 
constitutional element, if it may be called so, which allows 
of lichen, while some slight disturbance is the immediate 
provocative. Most often this is gastric disturbance or indi- 
gestion during dentition ; sometimes it is the irritation of 
flea-bites ; sometimes, again, as Hutchinson suggests, a vari- 
cella or some other exanthem. Hutchinson distinguishes 
between a prurigo due to varicella and that due to other 
causes, by the former being vesicular the latter not; but I 
cannot think that this distinction is of much service. Some 

* u Trans. Med. Chir. Soc," vol. lxvi. 



680 THE DISEASES OF CHILDREN. 

exceedingly practical and valuable remarks, however, are 
made concerning the production of a pruriginous skin by 
eruptions of any chronicity, for all must be familiar with the 
fact that to scratch an itching spot is not only to make the 
spot more irritable, but also to extend the actual area from 
which the abnormal sensation is transmitted. It is easy thus 
to make the body itch all over; and this condition begets a 
pruriginous habit of skin which is quite out of proportion to 
the external cause. 

Treatment. — Lichen urticatus is very obstinate. It and 
all three affections in this group are for the most part best 
treated by the strictest attention to the diet ; but it is in 
many cases very difficult to say exactly in what element the 
cause of indigestion lies. Some children are said to be 
worse when eating sugar, some when they have taken too 
much milk ; but I must confess to having been unable to 
reduce a not inconsiderable experience into concrete and 
dogmatic statements. 

Having already given full space to diet, I shall only say 
that it will require careful scrutiny and probably modifica- 
tion according to the rules already detailed. Next in impor- 
tance comes the necessity to deprive the surface as far as 
possible of all excuse for itching. This may be done both 
by external and internal means. Externally, the most scru- 
pulous attention is to be paid to cleanliness. The skin is to 
be bathed frequently ; the linen is to be changed frequently 
to ensure the absence of such pests as fleas ; and in hospital 
out-patients scabies and pediculi must be examined for and 
treated if present. The nature of the clothing next the 
skin must also be examined. Some people are unable to 
wear flannel, or particular kinds of flannel, merino, etc., and 
dyed flannels are sometimes in use which may account for 
external irritation. The itching of the papules may be 
mitigated by gently rubbing over them and the affected skin 



DISEASES OF THE SKIN. 68 1 

a lotion of bicarbonate of sodium, glycerine, and elder- flower 
or rose-water (F. 46), or a lotion of corrosive sublimate; 
half a grain to each ounce is sometimes effective (F. 47). 
Borax and glycerine may be used for the same purpose, or 
the skin may be oiled with vaseline or carbolic oil (1 to 40). 
Hutchinson recommends a solution of the liquor carbonis 
detergens (one part to four or five of water). 

For the more chronic cases, a tar bath may be given, by 
adding the liquor carbonis detergens to water; or sulphur 
baths are useful — a tablespoonful of sulphur, or more, to a 
bath. 

For internal administration in the acute stages, bicarbo- 
nate of sodium or potassium may be given, or some fluid 
magnesia. Either of the F. 7-1 1 will answer the purpose. 

For older children, quinine in full doses, or cod-liver oil, 
seems to be of most service. I think, also, that the confec- 
tion of sulphur and euonymin are of value in regulating the 
bowels and stimulating the liver. 

Acute Urticaria is far less common than the chronic con- 
ditions just described. It is readily recognized when the 
wheals are out, unless, as is sometimes the case, these are 
exchanged for a more or less general oedema, when the face 
becomes swollen, like the visage of a child with pertussis, 
and the subcutaneous tissues of the extremities are rendered 
somewhat brawny. When the wheals are not out, there 
may be also a difficulty, very little remaining but small 
red papules, with perhaps — when the itching has been 
severe — a subdued ecchymosis or dusky condition of the 
skin. 

Acute urticaria is certainly due immediately to errors in 
diet, though it is not unlikely that idiosyncracy may be the 
remote cause. It is to be treated by attention to the diet, 
and usually some alkali, as in F. 8 or 1 1, is all that is neces- 
sary. To allay the severe itching, bicarbonate of sodium, 



682 THE DISEASES OF CHILDREN. 

dissolved in equal parts of glycerine and water, or glycerine 
and rose-water, rubbed gently into the part, is one of the 
best remedies. Gentle friction with sweet oil is also useful ; 
and perhaps it is well to remark that whereas violent scratch- 
ing increases the irritation, gentle rubbing is one of the best 
calmatives possible to a pruriginous skin. 

Eczema is most commonly seen about the head, ears, and 
face, and in such other parts as are subject to chafing and to 
the irritation of excessive perspiration — in the creases of the 
neck, in the axillae, groins, scrotal and anal regions, and 
round the umbilicus. It may be hereditary, perhaps not as 
eczema from eczema, but from a rough or scurfy skin, or an 
abnormality of some sort. Like strophulus, it often owns 
an external cause which may be slight in comparison to the 
amount of the disease. In hospital out-patients it is often 
associated with scabies and pediculi — in both cases the erup- 
tion may be not only vesicular but pustular (eczema im- 
petigo). Eczema capitis is sometimes very chronic, and is 
one of the most obstinate affections of young children. 
Such cases sometimes remain for months in hospital and 
seem to derive no benefit from any remedy, notwithstanding 
that the child's general health improves or may even appear 
to be of the best. Eczema is a disease which has a distinct 
predilection for the first four or five months of life — twenty- 
five cases out of thirty-three, occurring in the first year of 
life, being under five months. Between one and two years 
the disease is common — ten cases in the thirty-six were over 
a year. From two to six years the disease is more evenly 
distributed, and after that it becomes uncommon. It is a 
disease which is often attributed to vaccination ; and I think 
it must be allowed that, although the charge is often a 
groundless one, nevertheless, in unhealthy children or those 
of pruriginous habit, it is a disease which is occasionally 
excited by the condition which vaccination engenders. It 



DISEASES OF THE SKIN. 



68 3 



may equally originate in a varicella, or after measles or any 
other exanthem. 

Treatment. — Acute Eczema. — This must be general and 
local. In the main, it requires careful dieting, abstinence 
from starch and saccharine matters, and the internal admin- 
istration of bicarbonate of sodium or potassium and nux 
vomica. A powder of bicarbonate of sodium (gr. v.) and 
sulphur (gr. v.) is a useful combination, and may be readily 
given in milk three or four times a day. Small doses of the 
tincture of rhubarb, the tincture of podophyllin, or of aloes, 
or of euonymin, may also be of service. A little hyd. c. 
cret. seems also to be useful in some cases ; and all these 
children are the better for a tonic of tartrate of iron after the 
rash has disappeared. 

For local applications, quite a number of things are useful 
at one time or another. In very acute cases, soothing ap- 
plications, such as lead lotion, will be required tempo- 
rarily ; but more generally the ung. metallorum (equal parts 
of the zinc, nitrate of mercury, and acetate of lead ointments) 
or some preparation of zinc. The zinc ointment is too 
thick; it may be made fluid by the addition of olive oil, or 
made with vaseline in place of the benzoated lard, or the 
oxide of zinc may be lightly dusted over the affected parts, 
after they have been freely smeared with olive oil. The 
glycerinum boracis is useful at times ; and for parts which 
require to be dried in some measure, the oleate of zinc, 
scented with thymol (Martindale), or the sanitary rose 
powder, is a useful preparation. 

In the more chronic and drier forms, arsenic and cod-liver 
oil are of most use internally; and as local applications, 
creasote ointment, or an application of the oil of cade one 
part, and vaseline four parts, or of any strength that may be 
deemed necessary. 

For chronic eczema of the scalp, the local application of 



684 THE DISEASES OF CHILDREN. 

cod-liver oil is sometimes of use, in addition to the internal 
administration of the drug. But these are cases which 
require the utmost patience and perseverance. 

In the eczema impetiginodes of the scalp, all that is 
usually necessary is to see to the destruction of all pediculi, 
the removal of all dry crusts, by softening them with 
oil and poultices, and the application of the ung. metallo- 
rum. 

In the patches of eczema so common about the face, a 
little unguentum metallorum is the best remedy. 

For intertrigo, the parts should be bathed two or three 
times a day, dried carefully with a soft towel, and then 
dusted over with sanitary rose powder or oleate of zinc 
above mentioned. 

Should these fail, one or other of the applications already 
mentioned may be tried. The parts should be covered up 
as little as possible. Soap should be avoided in eczema, 
except in very chronic cases, the bath being one of warm 
water, with some fine oatmeal added. 

Children with a tendency to eczema require attention to 
their food and occasional tonics, more particularly for some 
few weeks after an attack — a few drops of cod-liver oil twice 
or three times a day, or the lacto-phosphate of lime and 
iron, combined with a little arsenic. 

Impetigo is most common on the scalp, where it is very 
generally associated with pediculi. If the disease is exten- 
sive, it is better to remove the hair as closely as possible, 
apply poultices and oil to remove the crust, and subse- 
quently some unguentum metallorum to the pustular sores, 
and a weak carbolic oil to the rest of the scalp. When the 
sores have healed up, then come free washings with soap and 
water, and perhaps some ammoniated mercury ointment 
(gr. v. to the ounce of vaseline), to get rid of the pediculi. 
Impetigo may occur on other parts of the body as scattered 



DISEASES OF THE SKIN. 



685 



pustules. These usually indicate that the child is out of 
health, that it is fed too well or too ill, or wants change of 
air or tonics. This complaint, like eczema, is liable to be 
set up by and mask scabies. 

Impetigo Contagiosa has been described as a special 
form which occurs in epidemics, runs through a house- 
hold, and is preceded by febrile disturbance ; it is dis- 
tinguished, in short, by the characteristics of an exanthem. 
I have myself seen several children suffering from impetigo 
in one house. Dr. Tilbury Fox states that he has " again 
and again reproduced the disease in others by inoculation.'' 
The nature of the disease is still obscure. It is said by Fox 
to begin as a vesicular disease, and thus to differ from other 
forms of impetigo, and also from pustular scabies, with 
which it may be confounded. It seems possible that it 
might also be mistaken for varicella. 

Treatment. — The contents of the pustules being inocu- 
lable, care must be taken to prevent the pustules being 
scratched, and to render the pus harmless. This is best 
done, according to the author quoted, by an ointment of 
ammoniated mercury. Some tonic medicine will in all 
probability be advisable as well. 

Ecthyma occurs in unhealthy children, who usually re- 
quire tonics and cod-liver oil. The crusts which form on 
the sites of the bullae of pemphigus may look like ecthyma 
in some instances, and the fact should be remembered. The 
unguentum metallorum is a good local application. 

Furunculi, or boils, are common at all ages, but they are 
chiefly met with in young children from one to three years, 
and in boys of eight to ten or twelve. In the younger 
subjects they are more prone to appear as red brawny in- 
durations, hardly to come to a head, and they run a rather 
slow course. Boils are often exceedingly troublesome — 
not so much in the cure of any one, although this is no light 

5* 



686 THE DISEASES OF CHILDREN. 

matter, for the pain and depression caused is quite out of 
proportion to the size of the local malady — but in the fact 
that certain individuals are subject to them, and when one 
breaks out it may be followed by others, and the illness ex- 
tend over some weeks ; not only so, but the skin under 
these circumstances is in an irritable condition, and, unless 
great care be exercised, the original boil becomes surrounded 
by a number. This is more particularly the case where 
poulticing has been carried on with vigor. 

In adults, boils are often the result of over-feeding, and 
some of the most intractable cases I have met with have 
been in large eaters of meat; but in children this is not so. 
A deteriorated state is generally indicated, which requires 
more generous living and sometimes stimulants. Occasion- 
ally the boils refuse to disappear, except under change of 
air. They may occur on any part of the body, but the back 
of the neck is the most common seat, or the buttocks. I 
have in particular instances thought them due to defective 
drainage. 

Treatment. — Every household either has, or can learn 
from its nearest neighbor, a recipe both for plaster and 
nostrum for the speedy cure of boils, but there is nothing 
that can be said to show a large percentage of successes. 
Locally, the inflammation must be shielded from all irrita- 
tion (the pain they give, however, insures this), and they- 
may be kept moist by lead lotion or supple by vaseline or 
carbolic oil. In the early stages, the removal of the small 
head, and the insertion of a minute drop of the pharmaco- 
pceial glycerinum acidi carbolici, sometimes eases the pain 
and arrests the extension of the slough. Poultices and cold- 
water dressing, though in many respects grateful, are dan- 
gerously liable to provoke the' appearance of more. As 
internal remedies, Dusart's or Easton's syrup may be given, 
and maltine or stout. For growing boys of ten to fourteen 



DISEASES OF THE SKIN. 



687 



or more, a mid-morning meal of half a tumbler of stout, with 
some bread and butter, is a very good pick-me-up. 

Sulphide of calcium has been recommended as especially 
valuable, but on two rather contradictory grounds : one will 
recommend it as effective in procuring resolution, another 
as a means of bringing about softening and evacuation. I 
have sometimes thought it of use in the latter way, but it 
has often failed, and I am not sure of its value. In general 
terms, we must look out for any faults in diet, or faults in 
hygiene, and then, having remedied these, betake ourselves 
to general tonics, such as I have named, and to maltine or 
stout as a food. 

Herpes is most commonly seen round the mouth. Its 
usual appearance is that of a collection of crusts, the vesicles 
characteristic of the disease having become abraded and dry. 
It is often associated with ulceration of the gums, and is 
liable to accompany acute febrile disturbance of any sort. 
It is, however, very commonly seen in the out-patient room 
in conditions of feeble health, without any certain evidence 
of the pre-existence of fever. 

Herpes zoster, or shingles, is also common. It occurs as 
a crop of vesicles containing neutral or feebly-alkaline fluid, 
mapping out the distribution of one or other of the cutaneous 
nerves. Of ten cases, two affected the superficial cervical 
plexus; four the ilio-inguinal, lumbar, or cutaneous nerves 
of the thigh ; one the internal cutaneous of the arm ; three 
the intercostal nerves ; the right side was affected seven 
times. Six were boys, four girls. The complaint is, in my 
experience, as has also been stated by others, more common 
in children than in adults. It is said to occur only once in 
each individual ; a statement I can neither confirm nor con- 
fute. It is a disease which is associated with more or less 
pain for a few hours before and during the formation of the 
vesicles ; but this usually quickly ceases, the vesicles dry up, 



688 THE DISEASES OF CHILDREN. 

though remaining tender, and in four or five days the dis- 
ease is all but well. 

Herpes iris is rare : it is said to occur most frequently in 
the extremities, rarely on the face. In the two cases of 
which I happen to have notes it occurred in the latter situa- 
tion. It is recognized by a central vesicle, with secondary 
rings of vesicles, and more or less redness around them. 

Treatment. — Very little is required for any form of herpes. 
Some mild saline laxative may be given for a day or two, 
and, if the pain be severe, a small dose of opium : the saline 
is to be followed by a tonic* The eruption maybe treated 
by the application of some thick ointment, such as the un- 
guentum zinci, which in a measure protects the vesicles 
from friction, and thus eases the pain and gives time for 
them to shrivel ; or they may be kept well powdered with 
the sanitary rose powder, oxide or oleate of zinc; or they 
may be painted with flexible collodion. The part should be 
well covered with wool. 

Pemphigus is a not very uncommon disease in childhood. 
Two forms require mention, pemphigus neonatorum, and 
pemphigus occurring in children other than sucklings. 

To take the last first : it occurs usually in spare children, 
and, if extensive, may be associated with very obvious ill- 
health ; but this is not necessary. Its course is apyrexial 
in many cases. In three cases which have come under no- 
tice while writing this, one is a spare girl, but not in any 
strikingly wasted condition, nor by any means anaemic; 
another is a remarkably well-looking, stout country boy ; 
and the third — a boy, the disease having lasted for many 
months — as it is likely to do — is somewhat anaemic and thin. 

In all these cases there comes upon the healthy skin a 
patch of erythema. This may be bright-red from excessive 

* Quinia is very useful in herpes zoster. — Ed. 



DISEASES OF THE SKIN. 



689 



injection of the cutaneous capillaries, or a paler, more cop- 
pery tint. The patch becomes slightly raised, the cuticle 
becoming partially separated, and giving it a wrinkled, soft, 
leathery appearance. After this a full or flaccid bulla forms 
upon a slightly vascular non-indurated base, containing 
opalescent serum or thin puriform fluid. The vesicles rup- 
ture and dry after a certain time of tension, or gradually 
shrivel, with a dry crust forming in the centre. Ultimately 
the whole surface originally blistered becomes covered with 
a thin crust, which covers a superficial ulcer. This gradu- 
ally heals, and leaves behind it a brightly rose-colored or a 
coppery stain. 

Under arsenical treatment the blister formation is either 
entirely arrested or rendered abortive. In the latter case I 
have seen the trunk and extremities (legs particularly) cov- 
ered with coppery patches of slightly thickened skin, not at 
all unlike a condition of tinea versicolor on superficial ex- 
amination. 

It is a disease which is very prone to relapse and to recur 
through several years, but, according to Hutchinson, it is 
cured eventually under arsenical treatment. I have a case 
under my care at the present time which strikingly illustrates 
the tendency to relapse, the intractability as regards com- 
plete cure, but the ready temporary cure under the adminis- 
tration of arsenic — a boy of five and a half, who has been in 
the hospital twice, with an interval of some months, and who 
has been under medical treatment more or less for many 
months. Small doses of arsenic are of little use to him, but 
as soon as fifteen-minim doses are reached, the blebs shrivel 
and no fresh ones appear. But here comes his difficulty : a 
less dose fails to check the formation of vesicles ; the large 
dose, when continued for ten days or a fortnight, causes 
diarrhoea and vomiting, and necessitates its discontinuance. 

Pemphigus neonatorum is sometimes a disease of like 



69O THE DISEASES OF CHILDREN. 

character to that just described. It then appears as scattered 
bullae in various parts of the body, avoiding the soles of the 
feet and the palms, and but rarely affecting the scalp. 

Bullae have occasionally been seen upon the gums and 
mucous membrane of the mouth. More commonly, how- 
ever, it is more acute and more diffused, sometimes being 
more of the nature of a general dermatitis, and is frequently 
of syphilitic origin. Syphilitic pemphigus is particularly 
prone to affect the soles and palms. 

The descriptions of pemphigus vary much. One can there- 
fore only suppose that the disease varies in its symptoms. 
Thus, a cachectic form is described by some, because it 
occurs in unhealthy children ; a pyaemic by others, because 
it occasionally indicates some bad condition of blood ; some 
have witnessed a contagious form ; and it is described as 
being sometimes associated with fever, sometimes not. 

Diagnosis. — This is for the most part not difficult, for the 
existence of scattered blisters determines it. But when, as 
may happen, the bladders have dried and crusted, or the 
disease is acute and diffused, and the body is covered with 
eczematous-looking crusts, one may well hesitate before 
coming to a conclusion. 

Prognosis. — This is only grave in young infants, or in 
the diffused forms in cachectic, pyaemic, or syphilitic in- 
fants. 

Treatment. — English authorities now very generally 
assent to the doctrine that arsenic is curative of non-syphi- 
litic pemphigus. Abroad, opinion is by no means unani- 
mous, and, by many, general tonics and blood restorers, 
such as cod-liver oil, iron, etc., are preferred before other 
remedies. 

The evidence collected by Hutchinson in favor of arsenic 
is very strong. It has been corroborated by a large number 
of other observers, and it so rarely fails to relieve and, event- 



DISEASES OF THE SKIN. 



69I 



ually, to cure the disease, that it may fairly be called the 
treatment for pemphigus. Other means for improving the 
general health may well be resorted to at the same time, 
and, while such things as cod-liver oil, and iron are given 
internally, good food and fresh air should be provided also. 

For syphiJitic cases anti-syphilitic remedies, such as hyd. 
c. cret, or iodide of iron, are to be given internally, or a 
mercurial bath may be given externally, of a strength of two, 
three, or four grains to each gallon of water. 

The blebs may be powdered over with boracic acid or 
oleate of zinc, to encourage their shrivelling, drying, and 
healing. 

Psoriasis is often hereditary. It presents similar features 
in childhood to those of the disease in adults, and it is for 
the most part relieved by similar remedies — viz., the local 
application of tar soap and tar ointments, and the internal 
administration of arsenic ; but it is an intractable form of 
disease in children. The sapo carbonis detergens, or tere- 
bene soap, is good for these cases, and the oil of cade, one 
part to three of vaseline, with some oil of lavender, makes a 
serviceable ointment; as also does liq. carbonis detergens 
5j to vaseline §j to §ij. The ung. acidi chrysophanici (ten 
grains to the ounce of benzoated lard) is also a useful rem- 
edy, but must be used with care, as it sometimes produces 
oedema, and some slight local inflammation of the part to 
which it is applied. It also stains the skin and linen, but 
the color can be removed by benzol or weak solutions of 
potash (Martindale). 

Erythema may assume various forms, but I shall only 
mention erythema nodosum. It is not uncommon. It is 
characterized by raised and tender lumps, which appear 
most often about the legs, on the front of the shin, and about 
the calf. They are not so very uncommon over the exterior 
surface of the forearm. The lumps quickly change color 



692 the diseases of children. 

and pass through the phases of discoloration of a bruise, 
and gradually disappear. Erythema nodosum is often as- 
sociated with other forms of erythema, and has thus received 
the name of erythema multiforme. The disease occurs in 
rheumatic families, though not exclusively so (nineteen 
out of twenty-nine cases, see p. 585 •. It is usually attended 
by apparent ill-health, but the temperature is hardly raised. 

It is but seldom necessary to apply any local treatment, 
but, af-er paying attention to the bowels, a tonic of iron, or 
arsenic, or strychnia should be given. 

Sclerema Neonatorum hare.;}* comes within the range of 
practical medicine, it is so rarely seen. It appears to be a 
disease of the newborn amongst the poor of large towns, and 
to be more common in the winter than the summer months. 
The affection is stated to begin in the lower extremities as a 
hard or brawny cedema, which gradually spreads over the 
body. The suppleness of the skin becomes lost, and it is 
impossible to raise it with the fingers from the deeper parts ; 
skin, muscle, and bone appear as one solid log. The body 
heat sinks at the same time, the pulse becomes impercep- 
tible, the heart sounds almost inaudible, and may be the 
respirator}* movements are invisible. The infant thus be- 
comes ex y feeble, sucks little, takes little from the 
breast, and sin 

Parrot distinguishes between sclerema — in which the skin 
is hard and thickened by new material, whilst the fat is 
shrivelled and atrophied — and oedema of the new born ; 
but these two conditions have usually been confused. In 
this distinction he is followed by Henoch, and no doubt 
correctly. Of the cause of sclerema we are still quite in 
ignorance, but of cedema some cases originate in erysipelas, 
others in extreme atelectasis or weakness of the heart, and 
others, perhaps, in nephritis in early infancy, of which 
Henoch gives a case in an infant of four weeks old. 



DISEASES OF THE SKIN. 693 

In cither case, however, the actual result seems much the 
same, and the post-mortem examination reveals visceral 
changes of like character in both — viz., atelectasis, lobular 
pneumonia, and various other lesions of dubious meaning, 
such as capillary infarctions, etc. 

Gerhardt attributes sclerema in great measure to lowering 
of the body temperature in feeble premature children, and in 
this light he advocates careful feeding, either by wet-nurse or 
otherwise ; and all such means as will raise the temperature 
— warm baths, hot packs, etc. 

Seborrhcea is an affection of the sebaceous glands, and, 
as affecting the scalp, it is not uncommon in infants, leading 
to a thick caking of the scalp, usually about the front, and 
to a secondary dermatitis ; whilst in older children it occa- 
sionally produces a condition of intolerable scurf. In the 
former class of cases, the crusted material must be softened 
by carbolic oil and poultices, and then removed — the further 
reaccumulation of material must be prevented by plenty of 
soap and warm water, and, if necessary, friction of the scalp 
with unguentum myristicse or some other mild stimulant. 
In older children, the hair should be kept short, frequently 
well washed with soap, and the scalp stimulated by being 
well brushed at least twice a day. Oily applications, such 
as weak carbolic oil or vaseline scented with oil of lavender, 
are useful, inasmuch as they prevent the accumulation of the 
natural secretion, and thus make a far more healthy condi- 
tion of the affected glands. Boracic acid in glycerine is 
also useful in the same way, and acts, moreover, as a mild 
stimulant. 

There are various other affections of the skin which might 
be mentioned, but they are rare — I might almost say unim- 
portant — and may well be left to special works on the 
subject. I will only mention Keloid as not uncommon in 
vaccination scars, and therefore affording opportunity for 

59 






694 THE DISEASES OF CHILDREN. 

the study of the natural history of a very remarkable form 
of tumor, in that it tends to disappear spontaneously. 

Molluscum Contagiosum also, as a form of glandular 
tumor, occurring about the face, neck, chest, genitals, etc., 
which many assert to be contagious, is a disease which, 
insignificant in itself, is of great pathological interest. It is 
easily eradicated by nipping off the little masses with the 
nail, and, if necessary, applying some mild astringent, or 
touching the bases with caustic. 

Congenital Xanthelasma may also find mention, in that 
it also may help, though of very exceptional occurrence, 
to a clearer knowledge of a still obscure disease in the 
adult. 

There yet remain the important group of parasitic dis- 
eases. These are tinea, with which I shall couple alopecia 
areata for the sake of convenience, favus, scabies and pedi- 
culi. 

Tinea occurs in two forms — the body tinea, when it ap- 
pears as a red, scurfy, gradually spreading ring on face, 
neck, arms, or other parts ; and the scalp tinea, which re- 
quires a more detailed description. Both forms are due 
to the same fungus, the tricophyton tonsurans. This is 
seen in minute spores, .which form strings or thickly clus- 
tered masses, which have been compared to fish-roe, and 
which are indestructible by liq. potassae or by ether (the 
latter distinguishes them from small globules of fatty 
matter, which sometimes make a difficulty in diagnosis for 
the student). 

It occurs in the scalp as isolated patches, which are more 
or less bald ; or diffused, without any definite baldness any- 
where. The scalp often presents the appearance of eczema 
or seborrhcea, and sometimes, though rarely, there is pustu- 
lation. The characteristic of the disease is the existence at 
any part of short bristly stumps, or hair-follicles with a 



DISEASES OF THE SKIN. 



6 9 5 



central black dot (which is the hair broken off quite short, 
or the empty orifice occluded by dust), or persistently bar- 
ren, though slightly swollen, hair-follicles. The isolated 
patches are often red or scurfy ; but the diffused disease is 
very difficult to detect, unless the scalp be very carefully 
examined, and the short stumps of broken-off hair be made 
the special object of search. 

As regards the diagnosis, the disease is so common and 
so often overlooked, that a diseased scalp of any kind should 
always be examined with the possibility of its existence in 
view. Scurfy heads particularly require this, as the stumps 
are liable to be hidden beneath the scales. The scalp must 
be examined methodically, the hairs being turned up with a 
pair of forceps, and the roots examined with a lens. Any 
suspicious stump must be (as much of it as possible) ex- 
tracted, and the minute fragment examined under the mi- 
croscope, after adding a drop of liquor potassae to clear the 
parts. 

Prognosis. — Recent cases are for the most part readily 
curable under energetic treatment; when the disease has 
existed some months, it may be very intractable. Even 
recent cases, however, require a guarded opinion upon the 
speediness of recovery, for some children appear to form an 
unusually favorable soil for its growth, and the disease 
spreads with great rapidity, notwithstanding treatment. It 
is impossible to say what the conditions in the child may be 
which favor the growth of tinea. The late Sir Erasmus 
Wilson believed that they were those of a depressed vitality 
which required extra food, and tinea is no doubt often found 
in thin anaemic children ; but there is equally no doubt that 
it is not uncommon in those who appear to be in very good 
health. 

Treatment. — I shall only give a bare outline here. For 
fuller information the reader cannot do better than refer to 



696 THE DISEASES OF CHILDREN. 

Mr. Alder Smith's little book,* than which nothing could be 
more simple, precise, and admirable, and from which, fully 
convinced of its value by personal experience, I condense 
much of the advice which follows. Tinea upon the body is 
readily cured. Hyposulphite of sodium (5j ad §j), boracic 
acid dissolved in glycerine, iodine liniment, perchloride of 
iron, citrine ointment, and oleate of mercury, are all effective. 
Tinea upon the scalp is a much more troublesome affair, 
because the fungus dips down into the hair-follicles, and in- 
vades the hair itself. It is therefore difficult to get at the 
fungus, and of course this difficulty is proportionate to the 
duration of the disease. 

In all cases the hair upon, and for half an inch around, 
the patch is to be cut short. If the disease is at all exten- 
sive, the hair is to be cut to a two-inch length all over the 
head, a fringe being left back and front for the sake of the 
appearance. 

In recent cases the head is to be washed every morning, 
or every other morning, with carbolic soap, then well mop- 
ped with a lotion of hyposulphite of sodium (5j to the Sj). 
The actual patches may be blistered with glacial acetic acid, 
and afterwards some parasiticide applied — glycerine of car- 
bolic acid, one in five, is a good one ; but Alder Smith rec- 
ommends, above all things, an ointment of nitrate of mer- 
cury, sulphur, and carbolic acid (F. 48), which must be well 
pressed into the roots of the hair-follicles three times a day. 
Carbolic oil, one to ten, or F. 49, are good applications for 
the entire scalp. Epilation should be practiced over the 
diseased parts. 

When the disease is extensive, a weak ointment must be 
applied all over the head. If the head should become sore, 
the parasiticide is to be applied by painting only. 

* "Ringworm; its Diagnosis and Treatment," 2d edition. 



DISEASES OF THE SKIN. 



697 



In Chronic Ringworm the fungus will have reached the 
depth of the hair-follicles, and be more or less inaccessible 
to the effects of the parasiticide. Under these circumstances 
stronger remedies become necessary, and oleate of mercury 
appears to be one of the best applications. In children over 
ten, a ten per cent, solution may be used ; under five, a five 
per cent, solution. The oleate is to be well pressed into the 
diseased patches with a firm mop night and morning, the 
rest of the head being smeared with either carbolic oil or the 
weak compound ointment already mentioned (F. 48). If 
the disease is extensive, the oleate must be rubbed into the 
entire head. The head must not be washed oftener than once 
in ten days under the use of the oleate ; frequent washing 
impedes the penetration of the remedy. The hair must be 
kept short. This treatment will require to be continued for 
some time, often for several months. Mr. Alder Smith states 
that it is extremely rare for any ill effects to follow the use 
of the mercurial. 

In cases which resist even this treatment, the artificial 
production of kerion is recommended. This is, in short, the 
production of an cedematous inflammation of the scalp in 
such patches as are diseased. It must be done very cau- 
tiously, and only a small patch at a time, and the parents 
should be informed of the aim of the treatment. 

Croton oil is an efficient remedy for this purpose. This 
is painted on night and morning, and the part poulticed 
assiduously. In four or five days' time the scalp thus treated 
should be red, swollen, boggy, tender, and the stumps pro- 
truding from the swollen follicles. Epilation is then to be 
carried out, and carbolic oil, citrine and sulphur ointment, 
thymol, or some other parasiticide is to be applied to the 
surface. 

Water-dressing or weak carbolic oil may be applied to 
the parts until the inflammation subsides, when usually the 



698 THE DISEASES OF CHILDREN. 

disease is cured, and a smooth, shining, bald patch results. 
Some stimulant hair-wash is then to be rubbed into the bald 
patches night and morning, and the hair is soon reproduced. 
This treatment is severe, should never be applied to young 
children under seven or eight, and only in cases in which 
energetic treatment of milder fashion over a long time has 
failed to eradicate the disease. 

Preventive Treatment. — The disease is contagious, and 
liable to spread in families or schools ; therefore all brushes, 
combs, sponges, flannels, towels, etc., used by the infected, 
must be scrupulously kept separate, and no other child 
allowed to touch them. Caps, coats, comforters, etc., must 
be kept quite separate, and well baked when no longer 
needed, or, still better, destroyed ; all linen that will wash 
should be well boiled. The heads of all other children in 
the house should be well pomaded with a white precipitate 
ointment, scented so as to render it agreeable (F. 49), or 
with carbolic oil (1 to 10). They should also be frequently 
washed and examined once a week, so that no early spots 
may go undetected. Recent cases of the disease, or any 
case where the disease is extensive, should be isolated. In 
the very chronic cases, when the disease is well in hand, and 
the head effectively covered with a parasiticide, etc., the child 
may, if it be imperative, mix with other children, without 
much fear of the disease being communicated. It is, of 
course, better when possible to isolate the child until it is 
well. No boy should be sent back to school unless he be 
absolutely well, or the disease be well under treatment and 
the medical officer consents to his return, it being, of course, 
fully understood that continued supervision and treatment 
will be necessary. 

Ringworm is very liable to relapse, and no child should 
be considered cured until the new downy hair is growing 



DISEASES OF THE SKIN. 



699 



well and no stumps are to be seen, and this after several 
examinations made at intervals. 

Alopecia Areata is placed here because so much discus- 
sion has taken place as to whether it is or is not due to the 
growth of a fungus, and because, if it be not, it is a condition 
which might be mistaken for ringworm. The fact that 
authorities have hitherto been divided upon the parasitic 
nature of this affection seems to me to point unmistakably 
to the conclusion that there is a disease (alopecia areata) 
which is non-parasitic, and that ringworm sometimes puts 
on very much the same appearances. The majority of living 
dermatologists are of opinion that alopecia areata is not due 
to a fungus. Alopecia is of various kinds, and any one of 
them may be found in childhood ; but the disease, which 
occurs in patches, is apparently distinct from these, although 
the condition of the hair is, equally with them, one of simple 
atrophy. The cause of this atrophy is unknown ; it is said 
to be sometimes hereditary. The hair falls out in patches, 
which increase at the circumference, and sometimes the 
entire scalp becomes bald. It is a common disease of child- 
hood, and is treated — and as a rule successfully — by stimu- 
lant applications to the scalp. The expressed oil of nutmeg, 
well rubbed into the patch night and morning, is a good 
remedy. Another favorite prescription is tincture of can- 
tharides, carbonate of ammonium, spirits of rosemary, and 
water (F. 50). Tincture of iodine may be applied, or, if the 
case prove obstinate, a patch may be gently vesicated, if not 
too large, by blistering fluid or iodine liniment. Steiner 
quotes Rindfleisch as recommending a lotion of tincture of 
capsicum and glycerine, and it is one that I should think 
would prove useful. The child will probably be benefited 
by tonics and good living. 

Of Favus no lengthy mention is required, it is so rare. I 
have seen it only twice. Kaposi notes its occurrence fifty- 



700 THE DISEASES OF CHILDREN. 

six times in a total of nearly 26,000 cases of skin disease in 
a period of ten years. It appears as crusted cups of sul- 
phur-yellow color scattered over the scalp, and can scarcely 
be mistaken, though in very long-standing cases it may 
perhaps be so for the crusts of some other disease — pso- 
riasis, neglected eczema, seborrhcea, etc. The patches are 
more or less circular, of well-marked outline, situated round 
one or more hair-follicles, and when removed leave a moist, 
depressed surface of skin behind. Favus sometimes occurs 
upon the body, and sometimes affects the nails. 

The treatment is expressed, in short, by epilation, and 
the energetic application of some parasiticide afterwards. 
The ointment already given for tinea tonsurans may be rec- 
ommended. Kaposi states that it is unnecessary to epilate 
the hairs systematically all over the diseased area, all that 
is necessary being to take the hair in thin tufts — healthy and 
diseased indiscriminately — between such a thing as a spatula 
and the thumb, and then to make slight traction. By this 
means the diseased and loose hairs come away and leave the 
healthy behind, without causing pain. Any cakes of fungus 
must first of all be removed by the free inunction of oil, and 
by poulticing, and the parasiticide is to be rubbed in after 
every epilation. The disease is intractable, and requires 
long treatment. 

Scabies is a common ailment in the out-patient rooms of 
children's hospitals. It is often generalized over the body, 
it is often pustular, and it may be associated with an erup- 
tion of an eczematous appearance. It may in some cases 
be mistaken for eczema or impetigo, both common diseases 
in children; and it is also not easy to distinguish at first 
sight from lichen urticatus or strophulus, if the latter be very 
diffused and the skin scored by scratching. 

The diagnosis must be settled by detecting the acari. 
Should the burrows prove difficult to find, any eczematous 



DISEASES OF THE SKIN. 



70I 



crusts may be scraped and detached and examined under the 
microscope for fragments of the acari, or ova. 

The treatment consists of applying some parasiticide to 
the affected parts, and afterwards thorough bathing — the 
infected clothes being well boiled or baked. Sulphur is 
the commonest remedy ; half a drachm to an ounce of vase- 
line makes a good application. The late Dr. Tilbury Fox 
recommended an ointment of sulphur, ammoniated mercury, 
and creosote (F. 51). Iodide of potassium ointment is said 
to be very efficacious, and has the advantage of having no 
smell. To pustules and inflamed parts a soothing lotion, 
such as lotio plumbi, must be applied. When the disease 
is generalized, time is saved by rubbing the sulphur oint- 
ment into the whole surface, the child remaining in a well- 
sulphured shirt and sheets for forty-eight hours. A thorough 
bath is then given, and clean clothing put on. But this 
plan can only be followed when the skin is sufficiently sound 
to allow of it ; it is not advisable in eczematous or pustular 
conditions. It will then be necessary to single out such 
parts as admit of and require the parasiticide, and others for 
the emollient treatment. 

Pediculi are mostly seen in the head. As a broad rule, 
enlargements of the glands in the segment of the neck 
behind the ears are caused by impetigo of the scalp, and 
impetigo is always associated with pediculi. Pediculi are 
often present without thepustulation; but given the existence 
of the latter, the former will generally be found. They are 
for the. most part recognized by the existence of the ova on 
the hair ; these are readily recognized by their elongated 
shape and their adhesion to the hair. 

Treatment. — The hair should be thinned as much as 
possibly ; in boys it may be cropped close to the head. If 
the head is not sore, the hair may be bathed with vinegar 
and water, with the object of loosening the cement which 



702 THE DISEASES OF CHILDREN. 

unites the ova to the hair, and thus to allow of their re- 
moval by subsequent washing with soap and water. The 
ung. hyd. ammon., either undiluted or mixed with vaseline, 
and scented with oil of lavender, is perhaps, upon the whole, 
the best parasiticide. Some prefer a lotion of bichloride of 
mercury (two to four grains to the ounce), and benzol, is 
recommended by others ; but the ointment is, perhaps, 
safer than the one, and less repulsive than the other. 
Pediculi are not usually troublesome to eradicate, when 
once attention is directed to their existence. It perhaps 
more often happens that parents apply one thing after 
another to cure a sore head, and take no radical measures 
against the pediculi which are at the root of the mischief. 
When they are few in number, a fine comb and frequent 
washing with soap and water will easily remove them. 

One other point needs noting — viz., that pediculi are 
not always due to uncleanliness. It is no unfamiliar ex- 
perience, that the heads of patients in every way well 
tended may, as it were, suddenly swarm with vermin when 
disease has reached the stage of exhaustion preceding dis- 
solution ; and with children it is true, as I have said of tinea, 
that in ill health of any form, but particularly the thin mis- 
erable starveling, is the prey of these creatures of vulturous 
propensities. Fattening food and tonics are therefore very 
usually requisite in these cases. 



APPENDIX OF FORMULA. 



Aromatic spirit of ammonia, . 
Ipecacuanha wine, 
Tincture of yellow cinchona, 
Glycerine, .... 
Caraway-water to, 

One drachm three times a day. 



si- 

^ss. 
gss. 
gjss. 



2. 

Salicylate of sodium, gij. 

Liquid extract of liquorice, . . . . . . gss. 

Solution of acetate of ammonium, .... ^ss. 

Water to, . gij. 

Half a drachm to one drachm every three or four hours. 



Castor oil, 

Oil of sweet almonds, 
White sugar, 
Powder of acacia, . 
Cinnamon-water to, 

Two drachms for a dose. 



39- 

aft- 
si- 



Tincture of opium, 
Castor oil, 

Oil of sweet almonds, 
White sugar, 
Powder of acacia, . 
Cinnamon-water to, 

One or two drachms for a dose. 



njeiij. 

sy- 

3*j- 



704 



APPENDIX OF FORMULAE. 



5. 



Sulphate of magnesium, 
Tincture of capsicum, . 
Syiup of ginger, . 
Dill-water* to, 



A drachm three times a day 



gss. 



6. 

Manna, ....... 

Syrup, ........ 

Caraway-water to, ..... 

A drachm three times a day. 



3»J- 

Eh 



7. 

Spirit of nitrous ether, . 

Sulphate of magnesium, 

Oil of cajuput, .... 

Syrup of tolu, .... 

Solution of carbonate of magnesium,f 

A drachm twice or three times a 



3J- 

Si- 

S»j. 



day. 



8. 

Bicarbonate of sodium, . 
Tincture of nux vomica, 
Compound tincture of cardamoms, 
Syrup, 



3)- 

a* 



* Aqua anethi, Br. P. — Ed. 

j- Liquor magnesiae carbonatis (Fluid Magnesia), Br. P., contains : 
Sulphate of magnesium, ..... 2 ounces. 

Carbonate of sodium, ...... 2]/ 2 ounces. 

Distilled water, . a sufficiency. 

For method of preparation consult British Pharmacopoeia, or Stille and 
Maisch's Dispensatory, p. 839. 

This solution contains about thirteen grains of carbonate of magnesium to 
the fluid-ounce. — Ed. 



APPENDIX OF FORMULA. 



705 



Chloroform-water,* gss. 

Water to, gij. 

A drachm every six hours (Eustace Smith). 
In this prescription, the alkali causes the separation of the strychnia from 
the tincture of mix vomica, but the amount of the alkaloid is so small that it 
is still held in solution by the water. 

9. 

Bicarbonate of sodium, . . . . . £j. 

Solution of bismuth, ....... ^ij. 

Syrup of tolu, gij. 

Caraway- water to, ....... gij. 

A drachm four times a day. 

10. 

Bicarbonate of sodium, ^j. 

Subnitrate of bismuth, ....... ^ss. 

Compound powder of tragacanth,f .... ^ss. 

Syrup of tolu, gss. 

Caraway-water to, gij. 

A drachm three times a day. 

11. 

Bicarbonate of sodium, gjss. 

Tincture of rhubarb, . . . . . . . £ij. 

Syrup of orange, or ginger, gj. 

Infusion of calumba or peppermint-water to, . . . giij. 

One or two drachms three times a day. 

* Aqua chloroformi, Br. P., contains : 

Chloroform, . . 1 fluid-drachm. 

Distilled water, 25 fluid-ounces. 

Put into a two-pint stoppered bottle, and shake them together until the 
chloroform is entirely dissolved in the water. — Ed. 
f Pulvis tragacanthae compositus, Br. P., contains : 

Tragacanth, in powder, ...... 1 ounce. 

Gum acacia, in powder, ...... 1 ounce. 

Starch, in powder, ....... 1 ounce. 

Refined sugar, in powder, . . . .3 ounces. 

Rub them well together. — Ed. 



706 



APPENDIX OF FORMULAE. 



12. 



Sulphate of magnesium, 
Ipecacuanha wine, 
Raspberry vinegar, 
Water to, 



Si- 

|jss. 



Two drachms twice or three times a day. 



13. 



Euonymin, •. 
White sugar, 



Once, twice, or three times a day. 



gr. v. 



14. 

Podophyllin, . . gr. j 

Rectified spirit, . . . . . . . • 3J- 

One or two drops on sugar once or twice a day. 



15. 

Solution of arseniate of sodium, . . . . . £j. 

Glycerine, £ij. 

Compound decoction of aloes,* ..... 3 iij. 

Two drachms three times a day for a child of six to ten. 



* Decoctum aloes compositum, Br. P., contains : 

Extract of Socotrine aloes, . 
Myrrh, .... 

Saffron, .... 

Carbonate of potassium, 
Extract of liquorice, 
Compound tincture of cardamoms, 
Distilled water, .... 

For mode of preparation see British Pharmacopoeia, or Stille and Maisch's 
Dispensatory, p. 491. — Ed. 



120 grains. 

90 grains. 

90 grains. 

60 grains. 

I ounce. 

8 fluid- ounces. 

a sufficiency. 



APPENDIX OF FORMULA. 



707 



16. 

Solution of strychnia,* ....... ff^xx. 

Solution of pernitrate of iron,f . . . . • Z)- 

Glycerine, !§ss. 

Caraway-water to, . . . . . . . giij. 

Two drachms three times a day. 

17. 

Belladonna, . . . . . . . . gr. j. 

Glycerine, . . . . . . . . • ^j- 

Iron wine to, ........ §iij. 

Two drachms three times a day. 

18. 

Creasote, ......... ^ ij— iv. 

Syrup of tolu, . . . . . . . . %). 

Camphor-water to, §j ss . 

A drachm when necessary. 

19. 

Citrate of potassium, ....... 5jj. 

Solution of acetate of ammonium, .... giij. 

Ipecacuanha wine, . . . . . . . ^j. 

Syrup of mulberries, J . . . . . . . gss. 

Water to, . . . . . . . . . gij. 

A drachm every four hours. 

* Liquor Strychniae, Br. P., contains : 

Strychnia, in crystals, ...... 4 grains. 

Dilute hydrochloric acid, 6 minims. 

Rectified spirit, ....... 2 fluid-drachms. 

Distilled water, ....... 6 fluid-drachms. 

Mix the hydrochloric acid with four drachms of the water, and dissolve the 
strychnia in the mixture by the aid of heat. Then add the spirit and the 
remainder of the water. — Ed. 

f Equal to Liquor Ferri Nitratis, U. S. P.— Ed. 
J Syrupus mori, Br. P., contains : 

Mulberry juice, ...... I pint. 

Refined sugar, ...... 2 pounds. 

Rectified spirit, ...... 2}£ fluid-ounces. 

Heat the mulberry juice to the boiling-point, and when it has cooled filter. 
Dissolve the sugar in the filtered liquid with gentle heat, and add the spirit. 
—Ed. 



708 



APPENDIX OF FORMULAE. 



20. 

Bicarbonate of potassium, 
Oil of sweet almonds, . 
Glycerine, .... 
Compound powder of tragacanth, 
Caraway-water to, 

A drachm every four hours 



3'h 

gss. 

S l h 

£ss. 



21. 



Sulphate of magnesium, . . 


• 3J- 


Sulphate of iron, ....... 


• g r - V11 J 


Dilute sulphuric acid, 


. gss. 


Syrup of ginger, . 


. gss. 


Caraway-water to, ... 


. giv. 


Two drachms three times a day. 





22. 

Liquid extract of opium, ...... HJJxx. 

Sulphate of iron, ........ gr. xvi. 

Solution of carbonate of magnesia, . . . . .^ij- 
Syrup of ginger, 3J. 

Two drachms three times a day for children of five to ten years of age. 

23. 

Extract of logwood in powder, . . . . . gr. xx. 

Ipecacuanha wine, ....... Trjjxx. 

Opium wine, . . . . . . . . nj?x. 

Chalk mixture, ... . . . . . . gij. 

A drachm every four hours. 

24. 

Extract of logwood, . . . . . . . zij. 

Tincture of catechu, ....... ziij. 

s y ru P> 3 J J« 

Cinnamon-water, . . . . . . . . 5iij. 

Dose for a child two years old, two drachms (Hillier). 



APPENDIX OF FORMUUE. 



709 



25. 

Gallic acid, gr. x. 

Wine of opium, TTJJv. 

Rectified spirit, ........ ^jss. 

Chloroform-water to, ...... . 3Jss. 

A drachm three times a day. 



26. 



Sulphate of copper, 


• g r -j- 


Dilute sulphuric acid, ...... 


. 3ss. 


Spirit of chloroform, . . . . 


. gss. 


Syrup, 


• E [ 'h 


Caraway-water to, ...... 


. gjss. 


A drachm three times a day. 




27. 




Acetate of lead, 


. gr. viij 


Dilute acetic acid, ... . .. . • . 


. TT^XX. 


Opium wine, 


. njjx. 


Syrup, . ... . 


. giij. 


Water to, . 


. gjss. 



A drachm three times a day. 

28. 



Chlorate of potassium, ..... 


• si- 


Tincture of yellow cinchona, 


• =53- 


Dilute hydrochloric acid, .... 


• si- 


Syrup of mulberries, . . 


. gjss 


Water to, . . ... 


• • gvj. 



Half an ounce every three or four hours for children of eight or ten years. 



29. 



Compound tincture of camphor,* .... 


• 3J- 


Solution of acetate of ammonium, .... 


. siij. 


Citrate of potassium, ...... 


• 3J- 


Syrup of tolu, ' 


. gss. 


Water to, 


• §"j- 


One or two drachms every three hours. 





Equal : Tr. Opii Camphorata, U. S. P. — Ed. 
6o 



710 APPENDIX OF FORMULA. 

30. 

Bicarbonate of potassium, . . . . . . gj . 

Tartrate of iron, £j. 

Liquid extract of liquorice, ...... Jss. 

Water or compound decoction of aloes to, . . . giij. 

Two drachms three times a day. 

31. 

Oil of turpentine, ^ij. 

Honey, gjss. 

Compound powder of tragacanth, . . . . . gj. 

Peppermint- water to, ^vj. 

Two drachms three times a day. 

32. 

Dilute hydrocyanic acid, ...... rcjjyj. 

Bicarbonate of sodium, • S»j- 

Glycerine, ^ss. 

Caraway- water, ........ ^iij. 

A drachm every three or four hours. 

33. 

Calomel, gr. j. 

Resin of jalap, . . . . . . gr. ij. 

Scammony powder, gr. v. 

To be taken as a powder, with honey. 

Jalapine may also be conveniently administered by dissolving a gelatine 
lamel (Savory and Moore) in warm milk. 



34. 

Sulphate of iron, , gr. xij. 

Liquid extract of liquorice, 5ss. 

Compound decoction of aloes to, 5iij. 

Two drachms to half an ounce three times a day. 



APPENDIX OF FORMULA. 



711 



35. 



Ipecacuanha wine, 


. . . gij. 


Spirit of nitrous ether, . 


. & 


Syrup of tolu, .... 


. . . . gj. 


Glycerine, ..... 


. gss. 


Water to, 


. ■ . . m 



A teaspoonful as often as may be necessary. 

36. 

Alum, ........... gij. 

Boil in a pint of milk and sweeten. A tabiespoonful frequently. 



37. 

Tincture of digitalis, 

Solution of acetate of ammonium, . 

Spirit of nitrous ether, 

Syrup of tolu, .... 

Caraway-water to, ... 

A drachm every two hours, 



gjss. 



38. 

Ointment of nitrate of mercury, 

Glycerine, . 

Carbolic oil (1 x 4°)> . 



3i- 

Eh 



39. 



Carbolic acid, 
Glycerine, 
Caraway- water to, 



One or two drachms every four hours. 



gr. viij. 

a- 

3*. 



40. 



Iodoform, 
Eucalyptus oil, 
Glycerine or vaseline to, 



^ss. 
gss. 
3»J- 



712 APPENDIX OF FORMULA. 

41. 

Alum, ^ss. 

Ipecacuanha wine, ....... 3J SS - 

Syrup of tolu, ^ss. 

Dill water to, . . giij. 

Two drachms every three or four hours. 

42. 

Solution of arseniate of sodium, 3J. 

Benzoate of sodium, Q). 

Syrup of tolu, §j. 

Water to, giij. 

Two drachms three times a day. 

43. 

Chloride of calcium, 3J- 

Liquid extract of liquorice, . . . . . • S- 

Glycerine, 31J- 

Water to, giij. 

Two drachms three times a day. 

44. Simple Elixir. 

An American vehicle for the administration of medicines. 

Spirit of orange (oil 1, rect. spt. 9), . . . . ^ss. 

Rectified spirit, ........ ^ivss. 

Distilled cinnamon- water, ...... ^vj. 

s y ru P> • • iyj. 

Mix and filter. Twenty drops to be added to any mixture. 
(Martindale and Westcott.) 

45. 

Carbonate of ammonium, ...... gr. xxiv. 

Bicarbonate of potassium, ^ij. 

Liquid extract of liquorice, . . . . . . gss. 

Water to 3 giij. 

A drachm every three or four hours. 



APPENDIX OF FORMULA. 



713 



46. 



Bicarbonate of sodium, . 

Glycerine, 

Elderflower-water,* 



For a lotion. 



47. 



Perchloride of mercury, 
Chloroform, . 
Glycerine, 
Rose-water to, 



3y. 



gr. iij. 

TTJ^XX. 



For a lotion. 



48. 

Carbolic acid (Calvert's No. 2). 
Nitrate of mercury ointment. 
Sulphur ointment. 
The proportions will vary with the age of the child ; equal parts will be 
borne by children over ten. For younger children, or for more extensive 
application to scattered patches, the carbolic and citrine ointments must be 
diluted with two, three, or four parts of sulphur ointment. 

The pure crystallized carbolic acid must be used, or the ointment will 
change color ; and the citrine ointment must be quite free from any excess of 
nitric acid. 

The carbolic acid is to be thoroughly mixed with the sulphur ointment first, 
and the citrine ointment rubbed in last — no heat is to be applied. The oint- 
ment should be freshly made every week or ten days. (Alder Smith.) 



49. 



Ammoniated mercury, . 
Red oxide of mercury, . 
Essential oil of almonds, 
Benzoated lard, . 



g r - V J- 



** Aqua sambuci, Br. P., contains : 

Fresh elder flowers, separated from the stalks (or an 
equivalent quantity of the flowers preserved, while 

fresh, with common salt), 10 pounds. 

Water, . . . . . . . . .2 gallons. 

Distil one gallon. — Ed. 



7H 



APPENDIX OF FORMULAE. 



50. 



Carbonate of ammonium, 
Tincture of cantharides, 
Spirit of rosemary,* 
Water to, 



E ss - 
gss. 
gss. 



51. 



Sulphur, . . . . . 


. 3ss. 


Ammoniated mercury, .... 


. gr. iv. 


Creasote, ...... 


• nRiv. 


Oil of chamomile, .... 


. ^x. 


Lard, . . . . . ... 


■ ■ . s-- 



52. "Directions for making Artificial Human Milk" from 
Playf air's " Science and Practice of Midwifery" 

"Take half a pint of skimmed milk, heat it to about 96 , and put into the 
warmed milk a piece of rennet about an inch square. Set the milk to stand 
in a fender, or over a lamp, until it is quite warm. When it is set, remove 
the rennet, break up the curd quite small with a knife, and let it stand for ten 
or fifteen minutes, when the curd will sink. Then pour the whey into a 
saucepan, and let it boil quickly. Measure one-third of a pint of this whey, 
and dissolve in it, when hot, no grains of sugar of milk. When this third 
of a pint of whey is cold, add to it two-thirds of a pint of new milk and two 
teaspoonfuls of cream, and stir. The food should be made fresh every twelve 
hours, and warmed as required. The piece of rennet, when taken out, can 
be kept in an egg-cup, and used for ten days or a fortnight. 

" N.B. — It is often advisable during the first month to use rather more than 
a third of a pint of whey, as the milk is apt to be rather too rich for a newly 
born child." 

To this I would add that rennet can be procured of any butcher that kills, 
but in large towns these may be difficult to meet with. In this case some 
liquid essence of rennet may be used instead. 



* Spiritus rosmarini, Br. P., contains: 

Oil of rosemary, I fluid-ounce. 

Rectified spirit, 40 fluid-ounces. 

Dissolve. — Ed. 



APPENDIX OF FORMULAE. 



7^5 



53. Directions for the Artificial Digestion of Milk. (Roberts.) 

A pint of milk, diluted with a quarter of a pint of water, is divided into 
equal parts — one part being heated to boiling and the other remaining cold, 
and the two mixed. In this way the required heat is procured — an essential 
point, for the ferment is destroyed by a temperature of over 140 F. The 
dilution prevents the curdling of the milk on the addition of the digestive 
fluid. Into the milk thus prepared are put two teaspoonfuls of Benger's or 
Savory and Moore's liquor pancreaticus and twenty grains of bicarbonate of 
sodium, and the milk is then placed under a cosy near the fire. It is to be 
tasted occasionally, and as soon as a bitter taste is perceptible, the whole is 
boiled, to arrest any further action. It is then ready for use. 

It may be made more palatable by using skimmed milk, and restoring the 
cream after the digestion has been accomplished and the process stopped by 
boiling. 

If the digestion be allowed to proceed too far, the product is too bitter and 
unpalatable. 

[I prefer to peptonize, or artificially digest, milk by solid pancreatin. That 
prepared by Fairchild, Brothers and Foster, of New York, has proved most 
efficient in my hands. The mode of preparation is as follows : 

Into a clean quart bottle put 5 grains of Extractum Pancreatis, 15 grains 
of Bicarbonate of Sodium, and a gill of cool water. Shake ; then add a pint 
of fresh cool milk. 

Place the bottle in water so hot that the whole hand can be held in it with- 
out discomfort for a minute, and keep the bottle there for exactly thirty min- 
utes. At the end of that time put the bottle on ice, to check further digestion 
and keep the milk from spoiling. 

The degree of digestion is very easily regulated by the length of time in 
which the milk is kept warm. When the milk is digested so long that it 
acquires a slightly bitter taste, it is because the caseine has been entirely con- 
verted into peptone. It is very rarely necessary to carry the peptonizing to 
this point. Partially peptonized milk has no bitter taste — has, indeed, little ap- 
parent evidence of any change. 

After the contents of the bottle get warm, then every moment lessens the 
amount of caseine — the ingredient which is difficult to digest, and the degree 
of peptonizing necessary in each case is best determined by the readiness 
with which it is assimilated by the patient. 

Great heat destroys, or cold stops, the digestive action. It must be borne 
in mind that this is not a cooking or chemical process. The object is to sub- 
ject the milk to the action of the digestive principle at a temperature similar 
to that of the body. Always use fresh sweet milk. 

Peptonized milk may be sweetened to taste, or used for punch, with rum, 



716 APPENDIX OF FORMULA. 

etc., or made into jelly; it may be employed also in the preparation of such 
foods as ordinarily require the use of milk. 

In the preparation of food for bottle-fed infants, it is perfectly feasible to 
prepare the milk for each meal in the nursing-bottle. Thus, for an infant of 
five or six months : 

&. Ext. pancreatis (Fairchild's), . . . . . gr. xviij. 

Sodii bicarbonatis, ....... gr. xlviij. 

M. et ft. in chart, (waxed papers), No. xij. 

S. — Put one powder into the nursing-bottle with four ounces of water and 
four ounces of fresh sweet milk, keep warm for about half an hour before 
feeding ; sweeten a little.] 

54. Routine for Choreic cases treated by Massage, etc. 

At 5.30 A.M., half a pint of warm milk; 7 A.M., half a pint of milk and 
three slices of bread and butter (each slice an ounce in weight); 9.45 a.m., 
half an ounce of Kepler's malt extract in lemonade; 10 a.m., massage (fifteen 
minutes) followed by half a pint of warm milk; 12.30 P.M., rice pudding, 
half a pint of milk, green food and potatoes; 4.15 P.M., half a pint of warm 
milk, three slices of bread and butter, and an egg lightly boiled; 7 p.m., half 
an ounce of Kepler's malt extract in lemonade; 7.30 p.m., massage, followed 
by half a pint of milk. At the end of ten days or a fortnight the bread and 
butter is increased to four slices at 7 and 4.15 ; a lean chop is added to the 
midday meal, and an extra pint of milk is distributed over the twenty-four 
hours. 

I am indebted to Dr. John Phillips, Assistant Physician to the Chelsea 
Hospital for Women, for working out this diet. We have found it very 
useful. 



INDEX. 



Abdomen, 20 

enlargement of, 20 

examination of, 22 

in typhoid fever, 280 

retraction of, 471 
Abdominal disease, cry of, 18 

distention, 289 

neuroses, 117 

symptoms of, 1 17 

tubercle, 410 
Abscesses, glandular after scarlatina, 

186 
Abscess of lung during cancrum oris, 

■ 98 

peritoneal, 425 
Acute endocarditis, 602 
hydrocephalus, 464 
nephritis, 448 
pericarditis, 602 
spinal paralysis, 508 
tuberculosis, 393 

pathology of, 393 

discussion of, 394 

symptoms of, 395 

diagnosis of, 396 

prognosis of, 396 

treatment of, 397 
Administration of food, points as to, 

43 
Affections of the oesophagus, 113 
Ague. (See Malarial Fever.) 
Albuminuria, a sequel of measles, 161 

in diphtheria, 21 1 ? 217 

in scarlatina, 174, 179 
Alopecia areata, 699 
Alum in treatment of whooping-cough, 

276 
Anaemia, 631 

diagnosis of, 631 

prognosis of, 631 



Anaemia, treatment of, 632 

in malarial fever, 291 
Anasarca, 183 

in scarlatina, 182 
Anatomical lesions of cholera infan- 
tum, 74 

entero-colitis, 68 

ulcerative stomatitis, 92 
Anatomy, morbid, of acute diarrhoea, 

64 

atelectasis, 357 

bronchiectasis, 335 

bronchitis, 332 

cancrum oris, 98 

ch. diarrhoea, 8 1 

cirrhosis of liver, 436 

diphtheria, 219 

enlargement of spleen, 430 

intussusception, 145 

mumps, 252 

phthisis, 364 
• pleurisy, 38 1 

pneumonia, 340 

scarlatina, 190 

tabes mesenterica, 413 

typhoid fever, 283 

whooping-cough, 268 
Aneurism, 621 
Anterior polio-myelitis, 501 
Anuria, 443 
Anus, fissure of, 54, 59 

malformation of a cause of con- 
stipation, 54 
Aphthae, 91 

Aphthous stomatitis, 91 
Appendix of formulae, 703 
Appetites, faulty, 42 
Arachnoid, inflammation of the, 

455. 
Arsenic, tolerance of, 26 
Artificial human milk, 37 
Ascaris lumbricoides, 135 



61 



,-is 



INDEX. 



Ascite 

_ " ; _:- 
: r : : n:s ; :'. _ : - 
:". :. ". : ; - :: _: ~ 
treatmez: a : _:~ 

: >: 
Asses mi ; _: - 

: : 5 
.hing, 294 
Atelectasis, 3 5 4 
seat : J54 
ges : \ : :_ 

morbid anatomy of. 3 ' " 
diagnosis of, 3 5 
proguos 

:.:ment of, 360 

vhooping- cough. : 5 
in measles : jj 
: : 5 
A -.:/' : rase of constipa- 

tior. _:_ 
Atrop fa 

4.6 

cry : 
pulse of. 

treatment : 
progressive muscular 

: : 



I 



Lixtare, 200 

I 1 

1 : • _ 

rhoid fever, 2S9, 200 
Belladonna in treatment of whooping- 

::.:;:-.. :" 

Blood poisoning in ; : : 

E : ■. '. e .'. r. : .: r . : :. 
Boils see Furuwcuij 

Bowels, evacuations from. : : 1 



Bre.ii: . : : 

m 
; 

294 
in bronc. 
in pneumonia. 344 
of children. : 4 
Bromide of potassium, suscept b 

to, 25 
Bronchial affections in measles, 160 
phtr. ; _ 5 

.107 

:. : ;. ^ - : ? : ■= : :'. j. : > 

prognosis of, 409 

treatment of, 409 

Bronchiec : 

morbid anaton -5 

pr : g ; 36 

treatment of, 3 
::" 
: :~ 
.~toms of, :: ; 
duration c 
diagnos> 
P r 

chronic. 

- 

morbid anaton 

:ment of, 3 
dun : g : 

in typhoid fever. : B : 
Broncho-pneumonia, during whoop- 
ing-, 
in cancrum or s 
in measles, 16c. 






Bn 



Dphy of, 490 



Enlus, renal __- 

454 

symptoms : 



INDEX. 



719 



Cancrum oris, etiology of, 99 
age most common at, 99 
treatment of, 99 
nourishment ir.. 
: of nursing-bottles and nipples, 

Carpo-pedal contractions, 536 
Casts in urine in scarlatina, 1 " 5 
Cataract, zonular, 645 
Catarrhal spa-m, 303 

stomatitis, 90 
Causal factors of entero-colitis, 68 
Cause of diphtheria, 210 
Causes, exciting, of chorea. 572 
Causes of acute bronchitis, 3 : 7 

acute diarrhoea, 61 

acute laryngitis ] z 

:.:::- ur:::i;:;.. z 5 1 

:.~:::r = . _li v . j.z~ 

atrophy, 46 
zr::".:r.ie::-..=:5. }}~ 
cancrum oris, 99 
ch. bronchitis. 
*ch. diarrhcea, 77 
ch. laryngitis, 320 
ch. pneumonia. ] 
cirrhosis of liver, 436 
coli: 

constipati:: - 
coryza, 299 
cretinism. 5 5 2 
diseases of spleen, 429 

±r." :i:ct ::.--: : :" sjleen. 429 
enuresis. 4.5 : 
epilepsy, 541 
facial paralysis. 5 : 5 
flatulence, 50 
furunculi, 686 
:;;.:;:; :".:.= ir.itr. I r; 

heart disease. 598 

r.fzv.z'.zz':^. ': - 1 
hydrocephalus, 477 

:r.:"-.n::".= : : n—-.s: : -s. 5 }' 
infantile palsy, 497 
internal squint. 5 : " 
intussusception. [44 
laryngismus stridulus, 306 
— ■:;. = Its. ::.i 



Causes of mucous disease, 1 1 B 

nocturnal incontinence of urine, 

z ;:.•. r. :>. -il S 

pie 

pneumonia, J43 

retro-pharyngeal abscess, 1 1 1 

simple meningitis, 4 5 " 

simple wasting, 46 

stomatitis, 88 

stomatitis, catarrhal, 90 

stomatitis, ulcerative, 92 

v -:':.. z-z erit: r.::i-. 12 : 

ulcer of stomach 

vomiting, 126 
Cerebral disease, cry of, 

htrv. irrhrut. _:. : 

zz.tz\zz.:z.:z. 5.14 

sinuses, thrombosis of, 494 
Ctrvi :i. :7:~:z.:::r.:r. 52S 
Cheesy glands after whooping-cough, 

264, 265 
Chest, 20 

examination of. 2 2 

in whooping-cough, 258 
Czz'.tzi :t.:lzvizlz. z 5. 72. 

anatomical lesions of, "_ 

etiology o£ 74 

symptoms of, 74 

diagnosis of, 75 

prognosis of, 75 

treatment of, 75 
:h.:rri. 557 

symptoms of, 5 5 " 

definition of, 560 

history of, 562 

duration of, 562 

pathology of, 565 

tZ.lzy '-'-• ;~ > 

a;cr :: ~:=: frezuen: :::urren;e, 

exciting causes of, 572 

prognosis of, 574 

magna, 5 5 
Chrcnic Bright's disease, 449 

ringworm, 697 

:::::::.::/. : :". f 17 
Cirrhosis of liver, 435 

:iu ; t5 : :". _l_: ; 

symptoms of, 436 

morbid anatomy of. _ 
Cleft palate, 104 
Cold (see Coryza). 



720 



INDEX. 



Colds during dentition, 29 
Colic, 50 

symptoms of, 50 

causes o£ 50 

treatment of, 51 

flatulent treatment of, 52 
Collapse of lung, 354 
Coma in scarlatina, 177 
Complexions, 20 
Complications of diphtheria, 217 

measles, 161 

mumps, 251 

rickets, 646 

scarlatina, 177 

whooping-cough, 263 
Condensed milk, 36, 45 
Congenital disease of heart, 610 

xanthelasma, 694 
Constipation, 54 

causes of, 54 

treatment of, 54 

prescriptions for, 55 

diet for, 55. 

symptoms of in childhood, 57 

necessity of regular habits for re- 
lief of, 57 ' 

associated with sickness, 59 

obstinate, 59 

in typhoid fever, 289 
Contagion of scarlatina, 189 
Contagious nature of diphtheria, 210 

whooping-cough, 267 
Contagiousness of rotheln, 205 

thrush, 95 
Convulsions during chronic diarrhoea, 

79 . 
dentition, 29 
from worms, 138 

entero-colitis, 70 
infantile, 536 
in scarlatina, 173, 177 
treatment of, 199 
in scarlatinal nephritis, 182 
in whooping-cough, 263 
Coryza, 298 

symptoms of, 298 
causes of, 299 
chronic, 299 
treatment of, 30, 300 
Cotton jacket, 27 
Cough in laryngismus stridulus, 310 

pneumonia, 344 
Course of intussusception, 150 



Course of vaccine sore, 245 
Cowling's rule for dosage, 25 
Cows' milk, 34, 37 

prepared to resemble human 
milk, 49 
Craniotabes, 640 
Cretinism, 551 

causes of, 552 

morbid anatomy of, 553 

diagnosis of, 553 

prognosis of, 554 

treatment of, 554 
Crisis in pneumonia, 345 
Croup in measles, 161 • 
Crust of vaccine sore, 246 
Crying, 34 
Cry in chronic diarrhoea, 78 

kinds of, 18 

of atrophy, 47 
Cyanosis, 620 
Cynanche parotidea, 112 

a sequel, 1 12 

common termination of, 112 
Cystitis, 445 

treatment of, 445 



D. 

Deglutition, 24 

Dental symptoms of rickets, 646 

Dentition, 28 

time of appearance of milk-teeth, 

28 
occurrence of diarrhoea in, 29 

of vomiting in, 29 
convulsions during, 29 
bronchitis during, 29 
pneumonia during, 29 
.colds during, 29 
occurrence of indigestion during, 
30 
of strophulus during, 30 
coryza during, 30 
fever during, 30 
second, 31 

fever. (See Gastric Disorder.) 
Description of diarrhoea, 60 
Desquamation in rotheln, 206 

in scarlatina, 175 
Desquamative stage of measles, 160 
Diagnosis, differential, of causes of 
vomiting, 129, 132 
of measles and scarlatina, 191 



INDEX. 



721 



Diagnosis of acute diarrhoea, 65 

from acute enteritis, 65 
from intussusception, 65 
acute tuberculosis, 396 
anaemia, 631 
ascites, 427 
atelectasis, 359 
atrophy, 47 
bronchitis, 329 
bronchial phthisis, 408 
cholera infantum, 75 
chronic diarrhoea, 82 
cretinism, 553 
diphtheria from croup, 224 

from scarlatina, 226 

from tonsillitis, 227 
dysuria, 444 
encephalic tumors, 487 
enlargement of spleen, 431 
entero-colitis, 70 
epilepsy, 542 

external hydrocephalus, 484 
haemophilia, 627 
headache, 547, 548 
hemorrhage into substance of 

brain, 493 
hydrocephalus, 479 
idiocy, 553 
infantile palsy, 506 

from hemorrhage into cord, 
508 

from paraplegia from com- 
pression, 507 

from pseudo-hypertrophic 
paralysis, 508 

from rachitic paralysis, 507 
intussusception, 149 
laryngitis, acute, 315 

chronic, 320 
malarial fever, 292 
measles, 166 
mucous disease, 120 
mumps, 253 
pemphigus, - 690 
peritoneal abscess, 427 
peritonitis, 419 
phthisis, 368 

from empyema, 368 
pleurisy, 382 
pneumonia, 348 

from acute consolidation, 349 

from acute tuberculosis, 349 

from atelectasis, 349 



Diagnosis of pneumonia from menin- 
gitis, 349 

from pleurisy, 349 
progressive muscular atrophy, 523 
pseudo croup, 304 
pseudo-hypertrophic paralysis, 

522 
rheumatism, 588 
rickets, 651 
rotheln, 207 
scabies, 700 
scarlatina, 194 

from measles, 194 
scurvy, 630 
simple meningitis, 460 
simple wasting, 47 
syphilis, 672 
syphilitic hepatitis, 438 
tabes mesenterica, 414 
tinea, 695 
tonsillitis from diphtheria, 106 

from scarlatinal sore throat, 
106 
tubercular meningitis, 471 

from simple meningitis, 471 

from typhoid fever, 472 
tuberculosis from mucous disease, 

120 
typhlo-peritonitis, 424 
typhoid fever, 285 

from meningitis, 286 

from ulcerative endocarditis, 

287 

from tuberculosis, 286 
varicella, 243 

from pemphigus, 244 

from variola, 243 
vesical calculus, 454 
whooping-cough, 270 

from enlarged bronchial 
glands, 270 
worms, 137 

retrospective, of scarlatinal ne- 
phritis, 183 
Diarrhoea, 60 

description of, 60 

a symptom of disordered function, 

60 
of long standing, 61 
summer, 61 
acute, 61 

causes of, 61 

symptoms of, 63 






22 



INDEX. 



Diarrhoea, acute evacuations in, 63 
morbid anatomy of, 64 
diagnosis of, 65 

from acute enti 
from intussusception, 65 
::, 65 
treatment of, 65 
chronic. - 

dus beginning of, 76 
ises :". "" 
5ympf Mas ;f. "* 
intercurrent dis e a is e - 
symptoms of, in older chil- 
dren, 79 
lienteric ( diarrhee ner ease 

80 
symptoms of, 80 
morbid anatomy of, 8 1 
diagr 
prog: 

a complication of measles, 162 
during dentition, : 
in scarlatina, 1 " " 
Diet, 32 

.:ency of fee 
interval between me: 
cows 

infant foe 

condensed milk, y: 
quantity of milk required, 36 
goats' mi. 

whe; - 

peptonized milk 

artificial human mil 

strij 

wet-nurse, :- 

human milk, proper, ies :. S 

boiled flour, 39 

meal- _: 

likes and lisfikes be food, 42 

faulty : : : etite, _: 

points as to administration of food, 

43 

care of nursing-bottles and nip- 
ple?. 44 

_5 
- - - 

for cbioni 

for constipatior.. 55 

fbrmncons lisease, 120 

for thrush, 96 



Diet, for typhoid fever, 288 

Z :::ion of heart in scarlatina, 192 

simple of heart, 603 
Diphtheria, 210 

age of occurrence, 210 

r 2IO 

ccr. ss of, 210 

relation to othc :io 

n to crouT : : : 
incubation of, 211 
eruptive stage of, 211 

2 : : 
membrane of, 211 
albuminuria in, 211 
::.:r.T.^::'.. 212 

-Dtoms of, 2:2 
throat in. 212 
urine in. 2 : j 

paralysis of soft palate afte 
modifications c f 
causes of death in, 2 : 5 
blood poisoning in, 2 : 5 

: 1 5 
asthenia ii 
suffocation in, 216 
laryngeal, 216 

symptoms : : _ 
complications and sequelae of, 217 
albuminuria in . 2 : ~ 

morbid an 

patholog 

diagnosis from croup 

from scarlatina, 226 
endocarcti: 22 

heart-clot in, 226 

gnosis from tonsil 227 

treatment of, 227 
local treatment of, 2 : 
internal treatment of. 
tracheotomy in, 
treatment of paralysis of, 237 
afte: 

in scarlatina, 1 ~ - 
Diphtheritic paralysis, 218 
Directions for 

- ' 5 
hi:: - :_ 

Z isease of mediastinal glands after 
measles, 163 

the genito-urinary org 
441 



INDEX. 



• 723 



ses of the liver. 4 
lymphatic glands, 
nervous system, 455 
677 

remarks upon, 677 
Disinfection after scarlatina, 202 
Disorders of movement, 496 
Dosag. 

Dropsy of scarlatina, 1 7 3 
treatment of, 198 
without albuminuria in scarlatinal 
nephritis, 183 
Dura arachnoid, inflammation of, 455 
n of chore*. 562 
intussusception, 150 
mumps, 250 
typhoid fever, 2 ; j 
whooping-cough, 261. 268 
Dysentery, 87 

yms of, 87 
toms of, 87 
treatment of, 87 
Dyspepsia, acute. See Gastric Dis- 
order.) 
-v.ria, \<\<\ 

, j j t 
diagnosis of, 4__ 
treatment of, 444 



E. 

ifTections in measles, 161 
m :. . 685 

during chronic diarrhoea, 79 
Eczema, 682 

description of, 682 

time of most frequent occurrence, 
682 

treatment. 

during chronic diarrhoea. 7; 
Ejecta, 24 
Empyema. 575 

after scarlatina, 186 

prognosis of, 35^ 

treatment of, 3 
Encephalic tumor-, i B 5 

symptoms or", 485 

optic neuritis in, 

morbid anatomy of, 486 

diagnosis of, 487 

prognosis of, 4SS 

treatment of, 488 



Endocarditis after scarlatina, 186 

acute, 602 

in diphtheria, 226 

in scarlatina, 177 
Enema for cholera infantum. ~ 

for constipation 

for entero-colit i 
Enemata for thread worms, 140 

in chronic diarrhoea, 86 

method of giving. 

Enlargement of spleen, 429 

ises of, 429 

morbid anatomy of, 430 
mptoms of, 430 

diagnosis ::. .131 

prognc sis ::, 431 

treatment of, 432 
Enteritis, acute diagnc = i~ from acute 

diarrhoea. 65 
Entero-colit: s, 6 S 

age at which, most frequent. 68 

class most common in, 68 

anatomical lesions of, 68 

etiology of, 68 

symptoms of, 69 

vomiting in, 69 

stools in, 69 

tongue of, 69 

temperature in, 69 

wrahting in. 70 

fontanelle in. 73 

skin in. ": 

convulsions in. 70 

diagnosis of, 73 

prognosis of, 70 

treatment of, 70 

prescriptions for, 73 
Enuresis. 4.51 

Epidemic nature of rotheln, 205 
of scarlatina, 173 
: : v. hooping-cough, 266 

roseola. -'See Rotheln. 
Epilepsy . :_: 

oe of occurrence, 541 

causes of. 541 

symptoms of, 541 

diagnosis of, 542 

prognosis of, 5^2 

treatment of, 542 
Epiphysial lesions in rickets, 642 
502 

treatment of, 302 

in whooping-cough, 263 



724 



INDEX. 



Equino varus, 506 
Eruption of rotheln, 205 

scarlatina, appearance of, 173 
time of appearance of, 173 
Eruptive stage of diphtheria, 211 

of measles, 15S 

of scarlatina, 173 
Erythema, 691 

Erythematous rash in thrush, , 95 
Essential paralysis. 496 
Etiology- of cancrum oris, 99 

cholera infantum, 74 

chorea, 568 

enterocolitis, 6S 

measles, 164 

mumps, 252 

rickets, 633 

scarlatina, iSS 

whooping-cough, 266 
Examination of abdomen, 22 

of chest, 22 

of child, 21 
Exanthems occurring in scarlatina, 177 
Exhaustion, cry of, iS 
External hydrocephalus, 4S3 

symptoms of, 4S4 

diagnosis of, 484 

treatment of, 4S4 
Eyes, appearance of, in whooping- 
cough, 25S 

F. 
Face, 19 

id cholera infantum, 75 

in chronic diarrhoea, 7S 
Facial paralysis, >,2^ 

causes of, 52^ 
Fauces, inflammation of, in scarlatina, 

177 

ulceration of, in scarlatina, 177 
Fecal distension, 421 

symptoms of, 422 
Fever, gastric, 2S0 

malarial, 291 

scarlet. 1 See Scarlatina.) 

treatment of, 30 

typhoid. 279 
First dentition, 2$ 
Fissure of anus, cause of constipation, 

54, 59 
Flatulence, 50, ^2 

of emptiness, 52 

treatment of, 52 



Flatulence from indigestible food, 52 
Flatulent colic, treatment of, *> 2 
Flavus, 699 

treatment of, 700 
Flour, boiled, 39 
Foetal rickets. 661 
Food in diphtheria, 231 

infants, 35 

points as to administration of, 43 

likes and dislikes to, 42 
Fontanelle, 19 

in entero-colitis, 70 
Foreign bodies in trachea, ^2^ 

treatment of, 324 
Formulae, 703 
Frequency of feeding, 32 
Functional disease of liver, 43S 
treatment of. 439 

nervous disorders. 545 
Fundus oculi in tubercular meningitis, 

470 
Furunculi, 6S5 

causes of. 6S6 

treatment of, 6S6 



Gangrene in chronic diarrhoea, 79 
Gangrenous stomatitis. | See Cancrum 

Or: 
Gastralgia. (See Gastric Disorder.) 
Gastric disorder, 114 

synonyms of, 1 14 

symptoms of, 114 

causes of, 115 

treatment of, 1 16 
Gastric fever. 2S3 

is infective, 2S0 
Gastro-malacia, 134 
German measles. (See Rotheln.) 
Glands, lymphatic, in scarlatina, 174 
Glandular abscesses after scarlatina, 
1S6 

affections in measles. 161 

symptoms of rickets, 645 
Glottis, direct spasm of, 305 
Goats' milk, 37 

H. 



Haemato-myelia, 50S 
Haematuria, 441 



INDEX. 



725 



Hematuria, causes of, 441 

treatment of, 443 
Haemophilia, 626 

symptoms of, 626 

pathology of, 627 

diagnosis of, 627 

prognosis of, 627 

treatment of, 627 
Haemoptysis in whooping cough, 263 
Harelip, 104 
Headache, 547 

causes of, 547 

diagnosis of, 547, 548 

symptoms of, 548 

treatment of, 549 
Head, hydrocephalic, 18, 475 

rickety, 18 

syphilitic, 18 
Heart burn, 56 
Heart clot in diphtheria, 226 
Heart dilatation 'of in scarlatina, 192 
Heart disease, 595 

variation of normal heart signs, 

595 

causes of, 598 

nature of valvular disease, 599 

acute pericarditis, 602 

endo-carditis, 602 

simple dilatation, 603 

symptoms of, 604 

prognosis of, 605 

treatment of, 606 

paracentesis of pericardium, 609 

symptoms in scarlatinal nephritis, 
i8r 
Hemiatrophia facialis, 526 
Hemiplegia, 511 

causes of, 511 

morbid anatomy of, 513 

symptoms of, 515 

prognosis of, 515 

treatment of, 516 

after scarlatina, 193 
Hemorrhage cerebral, 491 

into substance of brain, 492 
symptoms of, 492 
diagnosis of, 493 
prognosis of, 493 
treatment of, 493 

meningeal, 491 

symptoms, 492 

prognosis, 492 
Hepatic enlargement in syphilis, 637 



Hereditary syphilis. (See Syphilis) 
Herpes, 687 
iris, 688 
zoster, 687 
treatment of, 688 
Histology of tubucular meningitis, 466 
History of chorea, 562 
Human milk, artificial, 2>7 
Hunger, cry of, 18 
Hydrocephalic head, 18 
Hydrocephalus, 474 
acute, 464 
spurious, 474 
definition of, 475 
shape of head in, 475 
bones of skull in, 476 
. morbid anatomy of, 476 
causes of, 477 
symptoms of, 478 
diagnosis of, 479 
prognosis of, 481 
treatment of, 482 
tapping in, 4*83 
Hygiene in chronic diarrhoea, 85 
Hyperaesthesia, 471 
Hypertrophy of brain, 490 

of pharyngeal mucous membrane, 
no 
condition of parts in, no 
symptoms of, no 
treatment of, no 
of tongue, 104 
of tonsils, 108 

symptoms of, 108 
. treatment of, 109 



Icterus neonatorum, 433 

causes of, 433 

treatment of, 434 
Idiocy, 550 

causes, 550 
Impetigo, 684 

contagiosa, 685 

treatment of, 685 

during chronic diarrhoea, 79 
Incubation of diphtheria, 211 

of measles, 157 

of mumps, 249 

of rotheln, 205 

of scarlatina, 173 



726 



INDEX. 



Incubation of typhoid fever, 288 
of varicella, 240 
of whooping-cough, 255 
Indigestion chronic, 120 
during dentition, 30 
Infant foods, 35 
Infantile convulsions, 536 
causes of, 537 
symptoms of, 537 
diagnosis of, 538 
results of, 539 
prognosis of, 539 
treatment of, 540 
palsy, 49 6 

time of occurrence, 497 
causes of, 497 
symptoms of, 497 
characteristic features of, 499 
morbid anatomy of, 500 
pathology of, 500 
diagnosis of, 506 
prognosis of, 509 
treatment of, 509 
paralysis, 496 
remittent fever, 280 
spasm, 307 

history of, 307 
syphilis. (See Syphilis) 
Infectious nature of scarlatina, 188 
Infective gastritis, 280 
Inflammation of all the coats of caecum 
and appendix, 422 
symptoms of, 422 
of caecal mucous membrane, 422 

symptoms of, 422 
of the dura arachnoid, 455 
Inflammations after scarlatina, 186 
Inspiratory crow, 260 
Intra-cranial tumors, 485 
Inter-current disease during chronic 

diarrhoea, 79 
Internal strabismus, 526 

causes of, 527 
Intertrigo during entero-colitis, 73 
Interval between meals, 7,^ 
Introduction, 13 
Intussusception, 143 
description of, 143 
location of most frequent occur- 
rence, 143 
pathology of, 143 
age of most frequent occurrence, 
H3 



Intussusception, frequency of, 143 
cause of, 144 
morbid anatomy of, 145 
symptoms of, 147 
with strangulation, 148 
without strangulation, 148 
diagnosis of, 149 
course of, 150 
duration of, 150 
prognosis of, 150 
treatment of, 151 
table of cases operated on, 154 
diagnosis of, from acute diarrhoea, 

65 
Irregularity of pupils in worms, 138 



J. 



Jadelot's lines, 19, 70 
Jaundice, catarrhal, 434 

simple, 433 
Journey, preservation of milk for, 45 



K. 

Keloid, 693 

Kidney, sarcoma of, 449 

scrofulous, 446 
Kidneys in scarlatina, 191 



Labial discharges, 454 

treatment of, 454 

line, 20 
Laparotomy for intussusception, 154 
Laryngeal diphtheria, 217 
Laryngismus stridulus, 305 

causes of, 306 

nature of, 306 

time of year most frequent, 306 

symptoms, 309, 314 

wheezing, 310 

cough in, 310 

prognosis of, 310 

treatment of, 311 
Laryngitis, 312 

synonyms, 312 

acute simple, 312 
causes of, 312 



INDEX. 



727 



Laryngitis, acute simple, age at of 
most frequent occurrence, 

313 
symptoms of, 314 
diagnosis of, 315 
prognosis of, 315 
treatment of, 316 
acute membranous, 317 
chronic, 318 

origin of, 318 
diagnosis of, 320 
causes of, 320 
prognosis of, 321 
treatment of, 321 
cry of, 18 
in syphilis, 666 
Late rickets. (See Rickets.) 
Lepto-meningitis, 457 
Lesions, anatomical, of cholera in- 
fantum, 74 
of entero-colitis, 68 
of ulcerative stomatitis, 92 
Leucocythaemia, 405 
Lichen urticatus, 678 

description of, 678 
treatment of, 680 
during dentition, 30 
Lienteric diarrhoea, 80 

treatment of, 84 
Likes and dislikes to foods, 42 
Line, labial, 20 
nasal, 19 

oculo-zygomatic, 19 
Lines of Jadelot, 19, 70 
Lithsemia, 439 

treatment of, 440 
Long-standing diarrhoea, 61 
Lung, abscess of, during cancrum oris, 

9 8 

Lymphatic glands in scarlatina, 174 



M. 

Malarial fever, 291 

characters of, 291 
anaemia of, 291 
spleen in, 292 
symptoms of, 292 
stages of, 292 
diagnosis of, 292 
prognosis of, 292 
treatment of, 292 



Malformation of anus cause of consti- 
pation, 54 
of heart, 610 

symptoms of, 616 
prognosis of, 619 
treatment of, 620 
Massage in hypertrophied tonsils, no 
Masturbation, 139 
Meals, 40 
Measles, 157 

synonyms of, 157 
incubation of, 157 
prodromal stage of, 158 
cough in, 158 

eruption on soft palate in, 158 
eruptive stage of, 158 
character of eruption of, 158 
desquamation in, 160 
bronchial trouble in, 160 
modification in, 160 
complications of, 161 
sequelae of, 161 
etiology of, 164 
isolation in, 164 
morbid anatomy of, 165 
diagnosis of, 166 

from scarlatina, 166 
German, 167 
treatment of, 167 
ear affections in, 170 
bastard. (See Rotheln.) 
Mediastinal glands, disease of follow- 
ing measles, 163 
Melaena, 123 

neonatorum, 125 
Membrane of diphtheria, 21 1 
Membranous laryngitis, 317 

in measles, 161, 162 
Meningeal hemorrhage, 491 
symptoms of, 492 
prognosis of, 492 
treatment of, 493 
Meningitis following scarlatina, 186 
simple, 457 

causes of, 457 
symptoms of, 458 
diagnosis of, 460 
prognosis of, 461 
treatment of, 462 
tubercular, 464 

synonyms of, 464 
description of, 465 
histology of, 466 



728 



INDEX. 



Meningitis, tubercular, symptoms of, 
467- 
fundus oculi in, 470 
temperature in, 470 
diagnosis of, 471 
prognosis of, 472 
treatment of, 473 
Micrococci in blood of measles, 165, 
166 
of scarlatina, 190 
Milk. (See Diet of Children in 
Health.) 
condensed, 36, 45 
of asses, 37 
of cow, 34, 37 

prepared to resemble human- 
milk, 49' 
methods of preparing, 34 
of goats, 37 
human, artificial, 37 
properties of, 38 
peptonized, 37 . 

preservation of, for journey, 45 
quantity taken, 36 
Milk teeth, time of appearance, 28 
Modifications of measles, 160 

of scarlatina, 175 
Molluscum contagiosum, 694 
Morbid anatomy of acute diarrhoea, 64 
of cancrum oris, 98 
of chronic diarrhoea, 81 
of cretinism, 553 
of encephalic tumor, 486 
of hemiplegia, 513 
of hydrocephalus, 476 
of infantile palsy, 500 
of late rickets, 658 
of measles, 165 
of pseudo-hypertrophic pa- 
ralysis, 517 
of rickets, 647 
of syphilis, 670 
Morbilli, 157 

Mortality during dentition, 29 
iri whooping-cough, 261 
Mouth, syphilitic ulceration of, 102 

ulceration of, 102 
Mucous disease, 118 
symptoms of, 119 
causes of, 118 
course of, 119 
diagnosis of, 120 
treatment of, 120 



Mucous disease, diet for, 120" 

after whooping-cough, 266 
Mumps, 112, 249 

incubation of, 249 

symptoms of, 250 

swelling in, 250 

duration of, 250 

complications in, 25 1 

metastasis in, 251 

orchitis in, 251 

meningitis in, 252 

sequelae of, 252 

etiology of, 252 

morbid anatomy of, 252 

diagnosis of, 253 

treatment of, 253 
Muscular atrophy, progressive, 523 

symptoms of rickets, 645 



N. 

Nasal line, 19 

Natiform skull, 19 

Nature of valvular diseases, 599 

Nephritis, acute, 448 

Nephritis, scarlatinal, 179 
anasarca in, 182 
ascites in, 182 
convulsions in, 182 
heart symptoms of, 181 
oedema of lungs in, 182 
retrospective diagnosis of, 

183 

symptoms of, 181 
treatment of, 198 
unfavorable symptoms in, 

182 
urine in, 181 
Nervousness, 586 
Nervous symptoms of rickets, 645 
system, diseases of, 455 
in typhoid fever, 282 
Neuroses, abdominal, 117 
New growths of kidney, 449 

treatment of, 450 
Nightmare, 543 
Night terror, 543 

treatment of, 544 
Nocturnal incontinence of urine, 451 
causes of, 451 
treatment of, 452 
Nodding spasm, 523 



INDEX. 



729 



Noma. (See Cancrum Oris.) 

pudendorum, 454 
Nose, 298 

Nursing bottles and nipples, care of, 

44 

gmus, 527 

O. 

Obstinate constipation, 59 
Oculo-zygomatic line, 19 
CEdema of lungs in scarlatinal nephri- 
tis, 182 
CEsophagus, 113 

affections of, 113 
Oidium albicans, 93 
Oily matter in stools, 125 
Opisthotonos, cervical. 52S 
Opium, susceptibility of children to, 

Ophthalmia following measles. 170 
Optic neuritis in cerebral tumor, 4S6 
Orchitis during mumps. 251 

symptoms of, 252 
Otitis in scarlatina, 1S7 

in typhoid fever. 2S4 
Otorrhoea after scarlatina, treatment of, 

201 
Oxyuris vermicularis 135 
Ozaena, 299 

treatment of. ;oo 



Pain in pleurisy, 375 

in pneumonia, 344 
Palsy infantile. 496 
Paracentesis of pericardium, 609 
Paralysis, diphtheritic, 213, 21S 

essential, 496 

facial. ^2^ 

infantile, 496 

pseudo-hypertrophic, 517 

spastic, 529 
Parotitis. (See Mumps.) 

in typhoid fever, 2>4 
Paroxysm of whooping-cough. 25 S 
Pathology of acute tuberculosis, 393 

of chorea, 565 

of diphtheria, 219, 221 

of haemophilia, 627 

of infantile palsy, 500 



Pathology of intussusception, 143 

of purpura, 625 

of rickets, 650 

of whooping-cough, 266 
Pediculi, 701 
Pemphigus, 6SS 

diagnosis of, 690 

prognosis of, 690 

treatment of, 690 
Peptonized milk, 37 
Perforative ulceration of caecum and 

appendix, 423 
Pericarditis, acute, 602 
Peritoneal abscess, 425 

diagnosis of, 425 

treatment of, 426 
Peritonitis, 41 S 

causes of, 41 S 

symptoms of, 419 

diagnosis of, 419 

prognosis of, 420 

treatment of, 420 

tubercular, 410 
Perityphlitis. (See Typhlo-perito- 

xitis.) 
Pertussis. See Whooping Cough.) 

a sequel of measles, 162 
Pharyngeal diphtheria, 212 
Phthisis, 361 

description of, 361 

chest of subjects of, 362 

symptoms of, 363 

morbid anatomy of, 364 

complications of. 3 : 8 

diagnosis of, 36S 

prognosis of, 369 

treatment of, 370 
Physical examination of chest, 295 

signs of pleurisy. 377 
of pneumonia, 345 
Pitting in varicella, 243 
Pleurisy, 373 

causes of, 374 

symptoms of. 375 

physical signs of. 377 

morbid anatomy of, 381 

complications of, 3S1 

diagnosis of. ; s 2 

prognosis of, 3S4 

treatment of, 3S4 

during chronic diarrhoea, 79 

in whooping-cough, 264 
Pneumonia, 337 



I 



730 



INDEX. 



Pneumonia, kinds of, 357 

part of lung most frequently af- 
fected. 338 
sex oftenest affected, 339 

age most affected, 339 

morbid anatomy of, 340 

causes of, 343 

symptoms of, 344 

duration o\\ 344 

pain in, 344 

cough in, 344 

cerebral, 314 

respiration in, 345 

crisis in, 345 

urine in, 345 

physical signs in, 345 

complications of, 34S 

diagnosis of, 34S 

prognosis of, 349 

results of. 

treatment of, 350 

chronic, 351 

causes of, 351 

during dentition, 29 
Points in administration of food, 43 
Polypus of rectum, S2 

rectal, 124 
Polyuria, 444 

Post-hemiplegic chorea, 515 
Potassii bromidum, susceptibility to, 25 
Poultices, 27 
Prescriptions for constipation, 55 

for entero-colitis, 73 
Preventive treatment of scarlatina, 

201 
Prodromal stage of measles, 15S 

of scarlatina, 173 
Prognosis of acute bronchitis, 330 

of acute diarrhoea, 65 

of acute laryngitis, 315 

of acute tuberculosis, 396 

of anaemia, 631 

of atelectasis, 359 

of bronchial phthisis, 409 

of bronchiectasis, 336 

of cholera infantum, 75 

of chorea, 574 

of ch. bronchitis. 333 

of ch. diarrhoea, 82 

of ch. laryngitis, 321 

of cretinism, 5^4 

of empyema, 3S4 

of encephalic tumor, 488 



Prognosis of enlargement of spleen, 

431 

of entero-colitis, 70 

of epilepsy. 542 

of haemophilia, 627 

of heart disease, 

of hemiplegia, 515 

of hemorrhage into substance of 
brain, 493 

of hydrocephalus, 4S1 

of infantile convulsions, 539 

of infantile palsy, 509 

of intussusception, 150 

of laryngismus stridulus, 310 

of late rickets, 661 

of malarial fever, 

of malformation of heart, 619 

of meningeal hemorrhage, 492 

of pemphigus, 690 

of peritonitis, 420 

of phthisis, 

of pleurisy. 384 

of pneumonia, 349 

of pseudo-hypertrophic paralysis, 
522 

of retro-pharyngeal abscess, 1 12 

of rickets, 652 

of scarlatina, 195 

of scurvy, 630 

of simple meningitis, 461 

of spa-tic paralysis, 535 

of syphilis, 073 

of syphilitic hepatitis, 43S 

of tabes mesenterica, 415 

of tinea, 695 

of typhlo-peritonitis, 424 

of tubercular meningitis, 4 

of whooping-cough, 27 1 
Progressive muscular atrophy, ?2$ 
diagnosis of, 525 
treatment of, 525 
Prolapse of rectum. Si 
Prolapsus ani, treatment of, S3 
Pruritus ani. 138 
Pseudo-croup, 303 

diagnosis of, 304 

treatment of, 304 
Pseudo-hypertrophic paralysis, 517 

morbid anatomy of, 517 

features o(, 51S 

diagnosis o(, ^22 

prognosis of, 522 
Psoriasis, 691 



INDEX. 



731 



Psoriasis, treatment of, 691 
Pulmonary tuberculosis. (See Phth- 
isis). 
Pulse, 23 

in atrophy, 47 

of scarlatina, 174 
Purpura, 623 

pathology of, 625 

treatment of, 625 
Pyrexia, treatment of, 30 



Quantity of milk taken by a child, 36 
Quarantine in scarlatina, 189 



R. 

Rachitic skull, 480 

Rash of scarlatina, appearance of, 173 

rose, 167 
Rectal polypus, 124 

prolapse in entero-colitis, 69 
Rectum, polypus of, 82 

prolapse of, 81 
Recurrence of scarlatina, 179 
Red-gum. (See Lichen Urticatus.) 
Reflex spasm, 308 

vomiting, 132 
Regular habits for relief of constipa- 
. tion, 57 

Relapse in scarlatina, 179 
Relaxed throat, no 
Remittent, infantile, 280 
Renal calculus, 447 

treatment of, 448 

tumors, 449 
Respiration, 23, 294 

in pneumonia, 345 
Respiratory system, diseases of, 294 

asymetrical breathing, 294 

Cheyne-Stokes breathing, 294 

physical examination of chest, 

295 

percussion, 295 

respiratory murmur, 297 
Retraction of abdomen, 471 
Retropharyngeal abscess, in 

cause of, 1 1 1 

age at which most frequent, ill 

symptoms of, in 



Retro-pharyngeal abscess, prognosis 
of, 112 

treatment of, 112 
Retrospective diagnosis of scarlatinal 

nephritis, 183 
Rheumatism, 578 

description of, 578 

symptoms of, 583 

diagnosis of, 588 

causes of death in, 590 

treatment of, 590 

scarlatinal, 177, 187 
treatment of, 200 
Rickets, 633 

etiology of, 633 

symptoms of, 637 

head in, 637 

craniotabes in, 640 

epiphysial lesions in, 642 

muscular symptoms of, 645 

nervous symptoms of, 645 

zonular cataract in, 645 

glandular symptoms of, 645 

dental symptoms of, 646 

complications of, 646 

morbid anatomy of, 647 

pathology of, 650 

diagnosis of, 651 

prognosis of, 652 

treatment of, 653 

late, 657 

symptoms of, 657 
morbid anatomy of, 658 
prognosis of, 661 
treatment of, 661 

foetal, 661 

characteristics of, 662 
Rickety head, 18, 637 
Ringworm, chronic, 697 
Roseola. (See R6thkln.) 

diagnosis of, from scarlatina, 195 
Rose rash, 167 

spots in typhoid fever, 282 
Rotheln, 203 

synonyms of, 203 

description of, 263 

epidemic nature of, 204 

age at which most common, 205 

contagiousness of, 205 

quarantine in, 205 

definition of, 205 

incubation of, 205 

eruptive stage of, 205 



732 



INDEX. 



Rotheln, symptoms of, 206 

desquamation in, 206 

diagnosis of, 207 

treatment of, 207 

diagnosis of, from scarlatina, 194 
Rougeole anomale, 161 
Roundworm, 135 
Routine for choreic cases, 716 
Rubella. (See Rotheln.) 



Scabies, 700 

diagnosis of, 700 
treatment of, 701 
Scaphoid skull, 19 
Scarlatina, 172 

description of, 172 
age at which most frequent, 172 
epidemic nature of, 173 
incubation of, 173 
prodromal stage of, 173 

vomiting in, 173 

convulsions in, 173 

sore-throat in, 173 
eruptive stage, 173 
rash of, 173 

punctated character of, 173 
pulse of, 174 
sore-throat in, 174 
tonsils in, 174 
lymphatic glands in, 174 
albuminuria in, 174 ■ 
casts in urine in, 174 
temperature in, 175 
desquamation of, 175 
modifications of, 175 
complications of, 177 
ulceration of fauces in, 177 
inflammation of fauces in, 177 
convulsions in, 177 
coma in, 177 
diarrhoea in, 177 
rheumatism in, 177 
heart affections in, 177 
with exanthems, 177 
surgical, 178 
relapses in, 178 
recurrence of, 178 
sequelae of, 179, 188 

nephritis, 179 

albuminuria, 179 



Scarlatina, sequelae of, dropsy, 179 

time of appearance 

of, 179 
frequency of, 180 
duration of, 180 
nephritis of, symptoms of, 1 81 
heart symptoms of, 181 
urine in, 181 
unfavorable symptoms in, 

182 
convulsions in, 182 
oedema of lungs in, 182 
anasarca in, 182 
ascites in, 182 
retrospective diagnosis, 183 
dropsy without albuminuria, 

.183 

microscopic examination of 
urine in, 184 
serous inflammations after, 186 
empyema after, 186 
endocarditis after, 186 
meningitis after, 186 
glandular abscess after, 186 
sloughing of skin after, 186 
diphtheria after, 187 
otitis after, 187 
rheumatism following, 187 
synovitis after, 187 
etiology of, 188 
infectious nature of, 188 
contagion of, 189 
• quarantine in, 189 
morbid anatomy of, 190 
micrococci in blood of, 190 
kidneys in, 191 
dilatation of heart in, 192 
hemiplegia after, 193 
diagnosis of, 194 

from measles, 194 

from rotheln, 194 

from tonsillitis, 195 

from roseola, £95 
prognosis of, 195 
treatment of, 195 

of dropsy in, 198 

of convulsions in, 199 

Basham's Mixture in, 200 

of rheumatism in, 200 

of otorrhoea in, 201 

preventive of, 201 
disinfection after, 202 
Scarlatinal albuminuria, 179 



INDEX. 



733 



Scarlatinal dropsy, 179 

nephritis, 179 

rheumatism, 187 

synovitis, 187 
Scar of vaccina, 246 
Sclerema neonatorum, 692 
Sclerosis of brain, 490 
Scrofula, 403 
Scrofulous habit, description of, 398 

kidney, 446 

treatment of, 446 
Scurvy, 628 

diagnosis of, 630 

prognosis of, 630 

treatment of, 631 
Seat worms, 135 
Seborrhcea, 693 

treatment of, 693 
Second dentition, 31 
Selection of wet-nurse, ^ 
Sequelae of diphtheria, 217 

of measles, 161 

of mumps, 252 

of scarlatina, 179 

of syphilis, 671 

of varicella, 244 

of whooping-cough, 264 
Serous inflammation after scarlatina, 

186 
Sickness accompanied by constipa- 
tion, 59 
Simple anasarca, 183 

dilatation of heart, 603 

wasting. (See Atrophy.) 
Sniffles, 298 
Skin in cholera infantum, 75 

in ch. diarrhoea, 78 

in entero-colitis, 70 
Skoda's tympanitic resonance, 347, 

379 
Skull, natiform, 19 

scaphoid, 19 
Sleep, 24 

Sloughing of skin after scarlatina, 186 
Softening of stomach, 134 
Sore-throat a prodrome of scarlatina, 

173 

of scarlatina, 174 
Sore of vaccine disease, 245 
Spasm of glottis, 305 
Spastic paralysis, 529 

symptoms of, 530 

cases of, 530 



Spastic paralysis, prognosis of, 535 

treatment of, 535 
Spleen in malarial fever, 291 
Splenic enlargement, 429 
in syphilis, 667 
in typhoid fever, 283 
Sponging, 27 

in typhoid fever, 289 
Spurious hydrocephalus, 474 

symptoms of, 475 

treatment of, 475 
Stomach, softening of, 134 

tubercular ulceration of, 133 
Stomatitis, 88 

catarrhal, 90 

aphthous, 91 

ulcerative, 92 

gangrenous. (See Cancrum 
Oris.) 
Stools, blood in, 123, 148 

in acute diarrhoea, 63, 79 

in cholera infantum, 74 

in ch. diarrhoea, 78 

in dysentery, Sy 

in entero-colitis, 69 

in intussusception, 148 

in lienteric diarrhoea, 80 

in tubercular ulceration of intes- 
tines, 80 

oily matter in 125 
Strawberry tongue, 174 
Stoppings, 37 
Strophulus. (See Lichen Urticatus.) 

during dentition, 30 
Sudamina in typhoid fever, 282 
Suffocation in diphtheria, 216 
Summer diarrhoea, 61 
Surgical scarlatina, 178 
Susceptibility to bromide of potassium, 

25 
to opium, 25 
Symptoms, general, of vaccina, 246 
local, of vaccina, 245 
of abdominal neuroses, 117 
of acute bronchitis, 328 
of acute diarrhoea, 63 
of acute laryngitis, 314 
of acute tonsillitis, 105 
of acute tuberculosis, 395 
of ascites, 419, 427 
of atelectasis, 356 
of atrophy, 46 
of bronchial phthisis, 407 



62 



;34 



INDEX. 



Symptoms of bronchiectasis, 334 
of cancrum oris, 97 
of cholera infantum, 74 
of chorea, 557 
of ch, bronchitis, 332 
of ch. diarrhoea, 77 
of ch. diarrhoea in older children, 

79 

of ch. tonsillitis, 108 

of cirrhosis of liver, 436 

of colic, 50 

of constipation, 57 

of coryza, 298 

of diphtheria, 211 

of dysentery, 8j 

of encephalic tumors, 485 

of enlargement of spleen, 430 

of entero-colitis, 69 

of epilepsy, 541 

of external hydrocephalus, 484 

of fecal distension, 422 

of flatulence, 50 

of gastric disorder, 1 14 

of haemophilia, 626 

of headache, 548 

of heart disease, 604 

of hemiplegia, 515 

of hemorrhage into substance of 
brain, 492 

of hereditary syphilis, 663 

of hydrocephalus, 478 

of hypertrophy of pharyngeal mu- 
cous membrane, no 

of infantile convulsions, 537 

of infantile palsy, 497 

of inflammation of all the coats of 
caecum and appendix, 422 

of inflammation of caecal mucous 
membrane, 422 

of intussusception, 147 

of laryngeal diphtheria, 217 

of laryngismus stridulus, 309 

of late rickets, 657 

of malarial fever, 292 

of melaena neonatorum, 125 

of malformation of heart, 616 

of meningeal hemorrhage, 492 

of mucous disease, 117 

of mumps, 250 

of orchitis, 252 

of phthisis, 363 

of pleurisy, 375 

of pneumonia, 344 



Symptoms of pseudo-hypertrophic par- 
alysis, 518 
of relaxed throat, no 
of renal calculus, 447 
of retro-pharyngeal abscess, III 
of rheumatism, 583 
of rickets, 637 
of rotheln, 206 
of simple meningitis, 458 
of simple wasting, 46 
of sniffles, 298 
of splenic enlargement, 430 
of spastic paralysis, 530 
of spurious hydrocephalus, 475 
of stomatitis, 88 
of stomatitis, aphthous, 91 

catarrhal, 90 

ulcerative, 92 
of syphilitic hepatitis, 437 
of tabes mesenterica, 41 1 
of thrombosis of cerebral sinuses, 

495 

of thrush, graver cases of, 95 
without inflammation, 94 

of tubercular meningitis, 467 

of typhlitis, 422 

of typhoid fever, 279 

of typhlo-peritonitis, 421 

of ulcer of stomach, 133 

of varicella, 241 

of vomiting in nurslings, 127 

of whooping-cough, 257 

of worms, 137 

unfavorable in scarlatinal nephri- 
tis, 182 
Syncope in diphtheria, 215 
Synovitis, scarlatinal, 187 
Syphilis, hereditary, 663 

time of most frequent occurrence, 
663 

symptoms of, 663 

laryngitis of, 666 

hepatic enlargement in, 667 

splenic enlargement in, 667 

bone disease in, 667 

ulceration of tongue in, 670 

morbid anatomy of, 670 

sequelae of, 671 

diagnosis of, 672 

prognosis of, 673 

treatment of, 673 
Syphilis, infantile, 663 
Syphilitic head, 18 



INDEX. 



735 



Syphilitic hepatitis, 436 

symptoms of, 437 

diagnosis of, 438 
prognosis of, 438 
treatment of, 438 
ulceration of mouth, 102 



Tache cerebrale, 460, 471 
Tabes mesenterica, 410 

symptoms of, 411 

morbid anatomy of, 413 

diagnosis of, 414 

prognosis of, 415 

treatment of, 415 
Taenia mediocanellata, 136 

solium, 136 
Talipes equinus, 506 
Tape worms, 136 
Tapping in hydrocephalus, 483 
Temperature in bronchitis, 328 

in cholera infantum, 75 

in chronic diarrhoea, 79 

in entero-colitis, 69 

in measles, 161 

in pleurisy, 375 

in pneumonia, 344, 345 

in scarlatina, 175 

in stomatitis, 89 

in tubercular meningitis, 470 

in tubercular ulceration of intes- 
tines, 80 

in typhoid fever, 280, 281 
Tetany, 536 

Throat in diphtheria, 212 
Thrombosis of cerebral sinuses, 494 

symptoms of, 495 

treatment of, 495 
Thrush, 93 

without inflammation, 94 

contagiousness of, 95 

graver cases of, 95 

treatment of, 96 
Time of feeding in whooping-cough, 

.277 
Tinea, 694 

diagnosis of, 695 
prognosis of, 695 
treatment of, 695 
preventive treatment of, 698 



Tolerance to arsenic, 26 

to belladonna, 26 
Tongue, hypertrophy of, 104 

in cholera infantum, 75 

in chronic diarrhoea, 78 

in scarlatina, 174 

in typhoid fever, 283 

in acute diarrhoea, 63 

in entero-colitis, 69 

strawberry, 174 
Tonics in chronic diarrhoea, 8"J 
Tonsillitis, acute, 105 

diagnosis from diphtheria, 106 
from scarlatinal sore throat, 
106 

chronic, 108 

treatment of, 109 

diagnosis from scarlatina, 195 
Tonsils in scarlatina, 174 
Torticollis, 529 

Trachea, foreign bodies in, 323 
Tracheotomy for diphtheria, 231 

for foreign bodies in trachea, 324 
Treatment, 24 

of acute bronchitis, 331 

of acute diarrhoea, 65 

of acute laryngitis, 316 

of acute tuberculosis, 397 

of acute urticaria, 681 

of alopecia areata, 699 

of anaemia, 632 

of anuria, 443 

of aphthae, 91 

of ascites, 427 

of atelectasis, 360 

of atrophy, 48 

of bronchial phthisis, 409 

of bronchiectasis, 336 

of cancrum oris, 99 

of cerebral hemorrhage, 493 

of chorea, 575 

of ch. bronchitis, 333 

of ch. diarrhoea, 8^ 

of ch. laryngitis, 321 

of ch. tonsillitis, 109 

of ch. vomiting, 130 

of colic, 51 

of constipation, 54 

of coryza, 300 

of cretinism, 554 

of cystitis, 445 

of diphtheria, 227 

of diphtheritic paralysis, 237 



736 



INDEX. 



Treatment of dysentery, $7 
of dysuria, 444 
of eczema. 683 
of empyema, 385 
of encephalic tumors, 4SS 
of enlarged spleen, 432 
of entero-colitis, 70 
of enuresis, 451 
of epilepsy, 542 
of epistaxis, 302 
of external hydrocephalus, 4S4 
of flatulence, 51 
of flatulent colic, 52 
of favus, 700 

of foreign bodies in trachea, 324 
of functional disease of liver, 

439 

of furunculi, 6S6 

of gastric disorder, 116 

of hematuria, 443 

of haemophilia, 027 

of headaches, 549 

of heart disease, 606 

of hemiplegia, 516 

of herpes, oSS 

of hydrocephalus, 4S2 

of hypertrophy of pharyngeal 

mucous membrane, no 
of impetigo contagiosa, 685 
of infantile convulsions, 540 
of infantile palsy, 509 
of intussusception, 1 5 1 
of labial discharges, 454 
of laryngismus stridulus, 311 
of lichen urticatus, 0S0 
of lithsemia, 440 
of malarial fever, 202 
of malformation oi~ heart, 620 
of measles, 167 
of melsena neonatorum, 125 
of mucous disease, 120 
of mumps, 253 

of new growths in kidney, 450 
of nightmare or night terror, 544 
of nocturnal incontinence of 

urine, 451 
of otorrhcea in scarlatina, 201 
of pediculi, 701 
of pemphigus, 690 
of peritoneal abscess, 426 
of peritonitis, 420 
of phthisis, 370 
of pleurisy, 384 



Treatment of pneumonia, 350 

of progressive muscular atrophy, 

525 

of prolapsus ani, S3 

of pseudo-croup, 304 

of psoriasis, 691 

of purpura, 025 

of pyuria. 445 

of rectal polypus, 124 

of relaxed throat, no 

of renal calculus, 44S 

of retro-pharyngeal abscess, 1 12 

of rheumatism, 590 

of rickets, 053 

of roseola, 209 

of rotheln, 207 

of scabies, 701 

of scarlatina, 195 

of scarlatinal rheumatism, 200 

of scrofula, 403 

of scrofulous kidney, 446 

of scurvy, 631 

of seborrhea. 003 

of simple meningitis, 402 

of spastic paralysis, 535 

of spurious hydrocephalus, 475 

of stomatitis, 93 

aphthous, 91 

catarrhal, 90 

ulcerative. 02 
of syphilis, 673 
oi syphilitic hepatitis, 438 
o\ tabes mesenterica, 415 
of thrombosis oi cerebral sinuses, 

495 

of thrash, 94 

of tinea, 695 

of torticollis, 529 

of tubercular meningitis, 473 

of typhoid fever, 2SS 

of typhlo-peritonitis, 424 

of ulcer of stomach, 133 

of vaginal discharges, 454 

of varicella, 245 

of vomiting of nurselings, 129 

of warty growths of larynx, 

-^22 
of worms, 139 
of whooping-cough, 272 
preventive of scarlatina, 201 

Trycophyton tonsurans, 694 

Tubercular appearance, 362 
chest, 362 



INDEX. 



737 



Tubercular disease of liver, 432 
peritonitis, 410 

ulceration of intestines, 80 
of stomach, 133 
Tuberculosis. (See Phthisis.) 

acute, 393 

after whooping-cough, 265 

a sequel of measles, 161 
Tumor, intracranial, 485 

in intussusception, 148 

renal, 449 
Typhlitis, 422 
Typhoid fever, 279 

symptoms of, 279 

remittent type, 279 

temperature in, 280, 281 

nervous symptoms in, 282 

rose spots in, 282 

bronchitis in, 282 

splenic enlargement in, 283 

tongue in, 2S3 

duration of, 283 

morbid anatomy of, 283 

diagnosis of, 285 

incubation of, 288 

treatment of, 288 

diet of, 288 
Typhlo-peritonitis, 420, 423 

causes of, 420 

symptoms of, 421, 423 

diagnosis of, 424 

prognosis of, 424 

treatment of, 424 



U, 



Ulceration intestinal, 80 

of fraenum linguae, 103, 260, 

263 
of mouth, 102 

syphilitic, 102 
treatment of, 103 
of tongue in syphilis, 670 
of tonsils, 106 
tubercular, of intestines, 80 
Ulcer of stomach, 132 
Urine, absence of chlorides in pneumo- 
nia, 345 
in diphtheria, 213 
in scarlatinal nephritis, 181 



Urticaria, acute, 681 
pigmentosa, 679 



V. 



Vaccina, 245 

local symptoms of, 245 

course of sore, 245 

vesicle of, 246 

crust of, 246 

scar of, 246 

general symptoms of, 246 
Vaccination, 246 

means of introducing virus, 246 

kinds of virus used, 246 

scarification, 246 

puncture, 247 

abrasion, 247 

from arm to arm, 247 

with crust, 247 

with bovine lymph, 247 

age most suited to, 248 

point best suited for inoculation, 
248 
Vaginal discharges, 454 

treatment of, 454 
Varicella, 240 

incubation, 240 

eruptive stage of, 241 

symptoms of, 241 

diagnosis of, 243 

sequelae of, 244 

treatment of, 245 

following measles, 163 
Vesical calculus, 454 
Vomiting, 126 

of nurslings, 127 

as an acute symptom, 128 

differential diagnosis of, 129, 132 

of nurselings, treatment of, 129 

chronic, 130 

of older children, 132 

reflex, 132 

of brain disease, 132 

in acute diarrhoea, 65 

in cholera infantum, 74 

in dentition, 29 

in entero-colitis, 69 

in intussusception, 65, 148 

in meningitis, 471 

in scarlatina, 173 

in whooping-cough, 258 






738 



INDEX. 



W. 

Warty growths in larynx, 321, 322 

treatment of, 322 
Wasting. ( See Atrophy.) 

in cholera infantum, 75 

in chronic diarrhoea, 78 

in entero-colitis, 70 
Wet-nurse, selection of, 37 
Wheezing, 310 
Whey, 37 
White gum. (See Lichen Lrtica- 

TUS. I 

Whooping-cough, 255 
incubation of, 255 
symptoms of, first stage, 257 
duration of first stage, 257 
symptoms of second stage, 257 
paroxysm, 258 
vomiting of, 258 
appearance of eyes in, 25S 
chest in, 258 
the whoop of, 259 
ulceration of fraenum linguae in, 

260 
duration of, 261 

age at which, most frequent, 261 
mortality in, 261 
causes of death in, 262 
modifications of, 262 
complications of, 263 
results and sequelae of, 264 
etiology of, 266 



Whooping-cough, pathology of, 266 
epidemic nature of, 266 
morbid anatomy of, 26S 
diagnosis of, 270 
prognosis of, 271 
treatment of, 272 
a complication of measles, 161, 
162 
Worms, 135 

varieties, 135 
seat, 135 

habitat of, 135 

description of, 135 
round, 135 

description of, 135 

habitat of, 136 
tape, 136 

description of, 136 
symptoms of, 137 
diagnosis of, 137 
a cause of convulsions, 138 
treatment of, 139 
Wry neck, 529 

X. 

Xanthelasma congenital, 694 
Xanthelasmoidia, 679 



Zonular cataract, 645 



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